Provider Demographics
NPI:1629061783
Name:PROVENCIO, JEANNE (LPCC)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:
Last Name:PROVENCIO
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 S MAIN ST
Mailing Address - Street 2:STE. 129
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-1206
Mailing Address - Country:US
Mailing Address - Phone:505-525-5644
Mailing Address - Fax:505-647-2010
Practice Address - Street 1:505 S MAIN ST
Practice Address - Street 2:STE. 129
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-1206
Practice Address - Country:US
Practice Address - Phone:505-525-5644
Practice Address - Fax:505-647-2010
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0529101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health