Provider Demographics
NPI:1669018479
Name:BACA, JEANNETTE VERNA (EDD, LPCC)
Entity Type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:VERNA
Last Name:BACA
Suffix:
Gender:F
Credentials:EDD, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 VIA SOLE DR
Mailing Address - Street 2:
Mailing Address - City:ALGODONES
Mailing Address - State:NM
Mailing Address - Zip Code:87001-8078
Mailing Address - Country:US
Mailing Address - Phone:505-573-1439
Mailing Address - Fax:
Practice Address - Street 1:6612 GULTON CT NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4407
Practice Address - Country:US
Practice Address - Phone:505-888-1686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCCMH0177521101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional