Provider Demographics
NPI:1225206105
Name:JUMPSTART, LLC
Entity Type:Organization
Organization Name:JUMPSTART, LLC
Other - Org Name:JUMPSTART AUTISM CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:505-828-3837
Mailing Address - Street 1:8100 M4 WYOMING NE #406
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-6615
Mailing Address - Country:US
Mailing Address - Phone:505-828-3837
Mailing Address - Fax:877-182-8550
Practice Address - Street 1:8500 WASHINGTON ST NE STE A1
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-1861
Practice Address - Country:US
Practice Address - Phone:505-828-3837
Practice Address - Fax:877-828-1550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
NM0877103TC2200X, 103TC2200X
NM3302235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty