Provider Demographics
NPI:1770723777
Name:BALESTRIERI, JED JEROME (MSW, LCSW)
Entity type:Individual
Prefix:MR
First Name:JED
Middle Name:JEROME
Last Name:BALESTRIERI
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 WELLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-8230
Mailing Address - Country:US
Mailing Address - Phone:970-244-3822
Mailing Address - Fax:970-243-5984
Practice Address - Street 1:1405 WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-8230
Practice Address - Country:US
Practice Address - Phone:970-244-3822
Practice Address - Fax:970-243-5984
Is Sole Proprietor?:No
Enumeration Date:2009-03-03
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9928611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO31900038OtherTHE COLORADO MEDICAL ASSISTANCE PROGRAM - MEDICAID