Provider Demographics
NPI:1114703295
Name:PEMBERTON, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PEMBERTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9340 E RANCHO VISTA DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-7160
Mailing Address - Country:US
Mailing Address - Phone:928-713-2167
Mailing Address - Fax:
Practice Address - Street 1:711 S GRANITE ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303-4241
Practice Address - Country:US
Practice Address - Phone:928-713-2167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
AZLMSW-20883101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor