Healthcare Provider Details

I. General information

NPI: 1972151728
Provider Name (Legal Business Name): JESSE LEE BACA LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2019
Last Update Date: 05/05/2025
Certification Date: 05/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4210 MEADOWLARK LN SE
RIO RANCHO NM
87124-1021
US

IV. Provider business mailing address

PO BOX 158
ESPANOLA NM
87532-0158
US

V. Phone/Fax

Practice location:
  • Phone: 505-425-6788
  • Fax:
Mailing address:
  • Phone: 505-753-7218
  • Fax: 505-426-3492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCTB-2024-0200
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: