Healthcare Provider Details

I. General information

NPI: 1730002940
Provider Name (Legal Business Name): JACQUELYN DE'ANDA LSW, SWC, MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 COLORADO AVE
PUEBLO CO
81004-2005
US

IV. Provider business mailing address

329 COLORADO AVE
PUEBLO CO
81004-2005
US

V. Phone/Fax

Practice location:
  • Phone: 719-662-0329
  • Fax:
Mailing address:
  • Phone: 719-662-0329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLSW.0009927115
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: