Provider Demographics
NPI:1013433051
Name:WILLOUGHBY, JONATHAN R (LCSW)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:R
Last Name:WILLOUGHBY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 GEORGIA ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-5903
Mailing Address - Country:US
Mailing Address - Phone:505-459-1260
Mailing Address - Fax:
Practice Address - Street 1:2900 LOUISIANA BLVD NE STE H
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-3565
Practice Address - Country:US
Practice Address - Phone:505-459-1260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-22
Last Update Date:2024-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-10912104100000X, 1041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM55829848Medicaid