Healthcare Provider Details

I. General information

NPI: 1205740909
Provider Name (Legal Business Name): JONATHAN ROBERT BOHANNON LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6169 LOMA DE CRISTO DR
EL PASO TX
79912-6654
US

IV. Provider business mailing address

6169 LOMA DE CRISTO DR
EL PASO TX
79912-6654
US

V. Phone/Fax

Practice location:
  • Phone: 915-493-1296
  • Fax:
Mailing address:
  • Phone: 915-493-1296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number97604
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: