MEDICARE: JENNA RAE BANEGAS MA, LMHC, CSCS

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	101YM0800X	Mental Health Counselor	CTB-2023-1031	NM

General Provider Information

NPI Number	:	1811776800
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNA RAE BANEGAS MA, LMHC, CSCS

Provider Business Mailing Address
First Line	:	1383 LENOX AVE
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-0827
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1980 E LOHMAN AVE STE E
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88001-3194
Country	:	US
Telephone Number	:	575-489-4769
Fax Number	:

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

Provider Enumeration Date	:	09/27/2023
Last Update Date	:	01/01/2024

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