Provider Demographics
NPI:1932644788
Name:VAZQUEZ, JESUS (LPC)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:VAZQUEZ
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3333
Mailing Address - Street 2:
Mailing Address - City:SOMERTON
Mailing Address - State:AZ
Mailing Address - Zip Code:85350-3333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:928-259-2501
Practice Address - Street 1:3970 W 24TH ST
Practice Address - Street 2:SUITE 206
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-9255
Practice Address - Country:US
Practice Address - Phone:928-373-8041
Practice Address - Fax:928-259-2501
Is Sole Proprietor?:No
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC 16266101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional