Basic Information
| Provider Information | |||||||||
| NPI: | 1215273305 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRUNK | ||||||||
| FirstName: | JONATHAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 W. 21ST | ||||||||
| Address2: | |||||||||
| City: | CLOVIS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5757692345 | ||||||||
| FaxNumber: | 5757699013 | ||||||||
| Practice Location | |||||||||
| Address1: | 1621 SUTTER PLACE | ||||||||
| Address2: | |||||||||
| City: | CLOVIS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5759352345 | ||||||||
| FaxNumber: | 5757423182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2012 | ||||||||
| LastUpdateDate: | 03/17/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101Y00000X | 0167251 | NM | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 0167251 | 01 | NM | LICENSED MENTAL HEALTH COUNSELOR | OTHER |