MEDICARE: JONELLE BACA CSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396078333
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONELLE BACA CSW

Provider Business Mailing Address
First Line	:	2551 COORS BLVD NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87120-1213
Country	:	US
Telephone Number	:	505-471-5006
Fax Number	:

Provider Business Practice Location Address
First Line	:	2503 RIDGE RUNNER RD
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4972
Country	:	US
Telephone Number	:	505-454-8265
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2009
Last Update Date	:	06/25/2015

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Directions to “ JONELLE BACA CSW” Practice Location

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