Provider Demographics
NPI:1417145491
Name:BACA, JEANNETTE MADELENE (LISW)
Entity Type:Individual
Prefix:MS
First Name:JEANNETTE
Middle Name:MADELENE
Last Name:BACA
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6338
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87502-6338
Mailing Address - Country:US
Mailing Address - Phone:505-992-8900
Mailing Address - Fax:505-992-8905
Practice Address - Street 1:1918 HOPEWELL ST
Practice Address - Street 2:UNIT A
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3856
Practice Address - Country:US
Practice Address - Phone:505-992-8900
Practice Address - Fax:505-992-8905
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-065151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical