Provider Demographics
NPI:1861764466
Name:JARAMILLO, ANDRES NICHOLAS (LPC)
Entity type:Individual
Prefix:
First Name:ANDRES
Middle Name:NICHOLAS
Last Name:JARAMILLO
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 N DREAMY DRAW DR STE 145
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4668
Mailing Address - Country:US
Mailing Address - Phone:480-882-4545
Mailing Address - Fax:480-882-5814
Practice Address - Street 1:4131 N 24TH ST STE B102
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-6231
Practice Address - Country:US
Practice Address - Phone:480-882-4545
Practice Address - Fax:602-381-1341
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-30
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-17933101YM0800X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ506403Medicaid