Provider Demographics
NPI:1154175131
Name:FAJARDO, JOHN JOSEPH
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:JOSEPH
Last Name:FAJARDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 CAGUA DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-1829
Mailing Address - Country:US
Mailing Address - Phone:505-514-2840
Mailing Address - Fax:
Practice Address - Street 1:814 CAGUA DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1829
Practice Address - Country:US
Practice Address - Phone:505-514-2840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician