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 1:5400 GIBSON BLVD SE FL 4
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-4729
Mailing Address - Country:US
Mailing Address - Phone:505-254-4565
Mailing Address - Fax:
Practice Address - Street 1:5400 GIBSON BLVD SE FL 4
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-4729
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:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-10034104100000X
NMX-111071041C0700X
NMC-109121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM55829848Medicaid