Provider Demographics
NPI:1295784353
Name:MACK, JONATHAN TRIMBLE (EDM, LPCC)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:TRIMBLE
Last Name:MACK
Suffix:
Gender:M
Credentials:EDM, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1613
Mailing Address - Street 2:
Mailing Address - City:PERALTA
Mailing Address - State:NM
Mailing Address - Zip Code:87042-1613
Mailing Address - Country:US
Mailing Address - Phone:505-796-4004
Mailing Address - Fax:505-866-9278
Practice Address - Street 1:7109 PROSPECT PL NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4313
Practice Address - Country:US
Practice Address - Phone:505-796-4004
Practice Address - Fax:505-830-3264
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0086461101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health