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General NPI Number Information
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NPI Number | 1437474624
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Entity Type | Organization
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Legal Business Name | JONATHAN MACK COUNSELING
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Dates
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Enumeration Date | 03/31/2010
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Last Update Date | 04/03/2013
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Provider Practice Location Address
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Address Line | 2727 SAN PEDRO DR NE STE 105
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City | ALBUQUERQUE
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State | NM
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Zip | 87110-3368
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Country | US
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Telephone | 505-385-3963
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Fax | 505-807-9996
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Provider Business Mailing Address
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Address Line | 2727 SAN PEDRO DR NE STE 105
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City | ALBUQUERQUE
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State | NM
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Zip | 87110-3368
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Country | US
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Telephone | 505-385-3963
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Fax | 505-807-9996
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Authorized Official
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Title or Position | THERAPIST / OWNER
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Name | JONATHAN MACK
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Credential | LPCC
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Telephone | 505-385-3963
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 4272969
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License Number State | NM
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