Provider Demographics
NPI:1003004359
Name:BALDILLEZ, JEREMY JAMES
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:JAMES
Last Name:BALDILLEZ
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 1:505 S MAIN ST
Mailing Address - Street 2:STE 249
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-1206
Mailing Address - Country:US
Mailing Address - Phone:505-527-5823
Mailing Address - Fax:505-527-5886
Practice Address - Street 1:3100 OAK ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3425
Practice Address - Country:US
Practice Address - Phone:575-323-3354
Practice Address - Fax:575-523-3354
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-11
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM275299103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool