Healthcare Provider Details

I. General information

NPI: 1215551841
Provider Name (Legal Business Name): JACQUELINE MARIE VILLALOBOS GARRETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2020
Last Update Date: 04/07/2022
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 BLAINE RANCH ST
HENDERSON NV
89012-4805
US

IV. Provider business mailing address

1515 E TROPICANA AVE
LAS VEGAS NV
89119-6517
US

V. Phone/Fax

Practice location:
  • Phone: 512-769-6995
  • Fax:
Mailing address:
  • Phone: 512-769-6995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: