Provider Demographics
NPI:1215551841
Name:VILLALOBOS GARRETT, JACQUELINE MARIE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
Last Name:VILLALOBOS GARRETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 E TROPICANA AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-6517
Mailing Address - Country:US
Mailing Address - Phone:512-769-6995
Mailing Address - Fax:
Practice Address - Street 1:1404 BLAINE RANCH ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89012-4805
Practice Address - Country:US
Practice Address - Phone:512-769-6995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-29
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist