Provider Demographics
NPI:1134305881
Name:BANEGAS, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BANEGAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 S DIAMOND AVE
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030-4710
Mailing Address - Country:US
Mailing Address - Phone:575-546-0427
Mailing Address - Fax:
Practice Address - Street 1:3100 OAK ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3425
Practice Address - Country:US
Practice Address - Phone:575-323-3354
Practice Address - Fax:575-523-3354
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-11
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM324887103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool