Healthcare Provider Details

I. General information

NPI: 1457734022
Provider Name (Legal Business Name): JESSE UNSIOG BALETO MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2015
Last Update Date: 07/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1244 N MARINE CORPS DR SUITE 101
TAMUNING GU
96913-4308
US

IV. Provider business mailing address

244 N. MARINE CORPS. DRIVE SUITE 101
TAMUNING GU
96913
US

V. Phone/Fax

Practice location:
  • Phone: 671-647-8262
  • Fax: 671-647-8257
Mailing address:
  • Phone: 671-646-6956
  • Fax: 671-647-3541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMF-140
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: