Provider Demographics
NPI:1073088779
Name:PACHECO, JOSE GERARDO (LICSW, MSW)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:GERARDO
Last Name:PACHECO
Suffix:
Gender:M
Credentials:LICSW, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2690 NE KRESKY AVE
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-2412
Mailing Address - Country:US
Mailing Address - Phone:360-330-9595
Mailing Address - Fax:360-330-7865
Practice Address - Street 1:2690 NE KRESKY AVE
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-2412
Practice Address - Country:US
Practice Address - Phone:360-330-9595
Practice Address - Fax:360-330-7865
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW61310284104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2130547Medicaid