Provider Demographics
NPI:1053379321
Name:HARTSHORNE, JONATHAN (MDIV)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:
Last Name:HARTSHORNE
Suffix:
Gender:M
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 CARLISLE BLVD NE
Mailing Address - Street 2:SUITE 129
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-1600
Mailing Address - Country:US
Mailing Address - Phone:505-889-4921
Mailing Address - Fax:
Practice Address - Street 1:3200 CARLISLE BLVD NE
Practice Address - Street 2:SUITE 129
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-1600
Practice Address - Country:US
Practice Address - Phone:505-889-4921
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5699101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM01075772Medicaid