Provider Demographics
NPI:1750592432
Name:VENEGAS, JESSIE LYNN (BSW CACII)
Entity type:Individual
Prefix:MRS
First Name:JESSIE
Middle Name:LYNN
Last Name:VENEGAS
Suffix:
Gender:F
Credentials:BSW CACII
Other - Prefix:MISS
Other - First Name:JESSIE
Other - Middle Name:LYNN
Other - Last Name:CORDOVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSW
Mailing Address - Street 1:3513 SIEGAL WAY
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-8731
Mailing Address - Country:US
Mailing Address - Phone:171-967-6436
Mailing Address - Fax:
Practice Address - Street 1:3500 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1543
Practice Address - Country:US
Practice Address - Phone:171-954-5118
Practice Address - Fax:171-354-5119
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6354101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)