Provider Demographics
NPI:1235637919
Name:JACARUSO, KIMBERLY RITA
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RITA
Last Name:JACARUSO
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 1:2210 MIGUEL CHAVEZ RD UNIT 123
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-6933
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2210 MIGUEL CHAVEZ RD UNIT 123
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6933
Practice Address - Country:US
Practice Address - Phone:508-353-0361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MABUO960868252OtherBLUE CROSS BLUE SHIELD