Provider Demographics
NPI:1619103355
Name:BACON, JAIME LEE
Entity Type:Individual
Prefix:MS
First Name:JAIME
Middle Name:LEE
Last Name:BACON
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 1:2085 E DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-4804
Mailing Address - Country:US
Mailing Address - Phone:559-453-4405
Mailing Address - Fax:559-453-5111
Practice Address - Street 1:2085 E DAKOTA AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-4804
Practice Address - Country:US
Practice Address - Phone:559-453-4405
Practice Address - Fax:559-453-5111
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-09
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA251B00000XMedicaid