Provider Demographics
NPI:1598112112
Name:DE HERRERA, JIMMY (CAC II)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:DE HERRERA
Suffix:
Gender:M
Credentials:CAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3703
Mailing Address - Country:US
Mailing Address - Phone:303-772-3853
Mailing Address - Fax:
Practice Address - Street 1:1129 FRANCIS ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3703
Practice Address - Country:US
Practice Address - Phone:303-772-3853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACB.0007468101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)