Provider Demographics
NPI:1760960314
Name:BACON, JARED A (BT)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:A
Last Name:BACON
Suffix:
Gender:M
Credentials:BT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 PERKINS DR STE B
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3248
Mailing Address - Country:US
Mailing Address - Phone:575-526-6682
Mailing Address - Fax:575-647-3777
Practice Address - Street 1:120 WYATT DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2925
Practice Address - Country:US
Practice Address - Phone:575-526-6682
Practice Address - Fax:575-647-3777
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-04
Last Update Date:2018-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst