=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336448711
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY TRUJILLO L.P.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2011
-----------------------------------------------------
Last Update Date | 03/24/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5100 E HIGHWAY 90 SUITE B
-----------------------------------------------------
City | SIERRA VISTA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85635-2443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-559-0511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1067
-----------------------------------------------------
City | BISBEE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85603-2067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-559-0511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC-13644
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------