MEDICARE: JESSICA CHAVEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1073762605
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA CHAVEZ

Provider Business Mailing Address
First Line	:	1426 BIRCH ST
Second Line	:
City	:	CANON CITY
State	:	CO
Zip	:	81212-4428
Country	:	US
Telephone Number	:	719-269-9632
Fax Number	:	719-269-9632

Provider Business Practice Location Address
First Line	:	1426 BIRCH ST
Second Line	:
City	:	CANON CITY
State	:	CO
Zip	:	81212-4428
Country	:	US
Telephone Number	:	719-248-2170
Fax Number	:	719-269-9632

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2008
Last Update Date	:	07/01/2009

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