Provider Demographics
NPI:1851160402
Name:JACOBO PACHECO, JOSE GUADALUPE
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:GUADALUPE
Last Name:JACOBO PACHECO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 ASH AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NC
Mailing Address - Zip Code:27298-9643
Mailing Address - Country:US
Mailing Address - Phone:336-539-4341
Mailing Address - Fax:
Practice Address - Street 1:210 CHARLOIS BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1508
Practice Address - Country:US
Practice Address - Phone:704-440-3580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-22
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician