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General NPI Number Information
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NPI Number | 1659566313
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Entity Type | Individual
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Provider Name | JACQUELINE VIVANCO PEREZ LCSW
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Gender | Female
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Dates
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Enumeration Date | 09/06/2007
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Last Update Date | 02/04/2025
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Provider Practice Location Address
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Address Line | 1330 SAN PEDRO DR NE STE 108
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City | ALBUQUERQUE
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State | NM
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Zip | 87110-6744
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Country | US
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Telephone | 505-209-9227
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 72922
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City | ALBUQUERQUE
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State | NM
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Zip | 87195-2922
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Country | US
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Telephone | 505-209-9227
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | M-05571
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | I-07176
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License Number State | NM
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C07176
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License Number State | NM
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