Provider Demographics
NPI:1477386852
Name:JUMPSTART, LLC
Entity type:Organization
Organization Name:JUMPSTART, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:505-828-3837
Mailing Address - Street 1:8100 WYOMING BLVD NE M-4 ,#406
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113
Mailing Address - Country:US
Mailing Address - Phone:505-828-3837
Mailing Address - Fax:877-828-1550
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:505-633-8500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JUMPSTART, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty