Provider Demographics
NPI:1972151728
Name:BACA, JESSE LEE (LPCC)
Entity type:Individual
Prefix:MR
First Name:JESSE
Middle Name:LEE
Last Name:BACA
Suffix:
Gender:
Credentials:LPCC
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 158
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-0158
Mailing Address - Country:US
Mailing Address - Phone:505-753-7218
Mailing Address - Fax:505-426-3492
Practice Address - Street 1:4210 MEADOWLARK LN SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1021
Practice Address - Country:US
Practice Address - Phone:505-425-6788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2024-0200101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional