Provider Demographics
NPI:1487203501
Name:BALLEJOS, JEANNIE
Entity Type:Individual
Prefix:
First Name:JEANNIE
Middle Name:
Last Name:BALLEJOS
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 1:2701 CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3869
Mailing Address - Country:US
Mailing Address - Phone:719-561-1300
Mailing Address - Fax:
Practice Address - Street 1:2701 CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3869
Practice Address - Country:US
Practice Address - Phone:719-561-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTA0012452225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant