Healthcare Provider Details

I. General information

NPI: 1669018479
Provider Name (Legal Business Name): JEANNETTE VERNA BACA ED.D., LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2019
Last Update Date: 11/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6612 GULTON CT NE
ALBUQUERQUE NM
87109-4407
US

IV. Provider business mailing address

16 VIA SOLE DR
ALGODONES NM
87001-8078
US

V. Phone/Fax

Practice location:
  • Phone: 505-888-1686
  • Fax:
Mailing address:
  • Phone: 505-573-1439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCCMH0177521
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: