Provider Demographics
NPI:1881835155
Name:JAQUEZ, DEANNA DOREEN (SLP)
Entity Type:Individual
Prefix:MRS
First Name:DEANNA
Middle Name:DOREEN
Last Name:JAQUEZ
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:MISS
Other - First Name:DEANNA
Other - Middle Name:DOREEN
Other - Last Name:BANEGAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:505 S MAIN ST
Mailing Address - Street 2:SUITE 249
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-1206
Mailing Address - Country:US
Mailing Address - Phone:575-527-5823
Mailing Address - Fax:575-527-5886
Practice Address - Street 1:505 S MAIN ST
Practice Address - Street 2:SUITE 249
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-1206
Practice Address - Country:US
Practice Address - Phone:575-527-5823
Practice Address - Fax:575-527-5886
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-17
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4479235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist