Provider Demographics
NPI:1659566313
Name:PEREZ, JACQUELINE VIVANCO (LISW)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:VIVANCO
Last Name:PEREZ
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 1:1101 MEDICAL ARTS AVE NE
Mailing Address - Street 2:BLDG 3-300
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2706
Mailing Address - Country:US
Mailing Address - Phone:505-842-5300
Mailing Address - Fax:505-765-1100
Practice Address - Street 1:1101 MEDICAL ARTS AVE NE
Practice Address - Street 2:BLDG 3-300
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2706
Practice Address - Country:US
Practice Address - Phone:505-842-5300
Practice Address - Fax:505-765-1100
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-05571104100000X
NMI-071761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker