Provider Demographics
NPI:1922792498
Name:BACA, JESSICA VICTORIA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:VICTORIA
Last Name:BACA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8512 MESA SPRINGS AVE SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-7036
Mailing Address - Country:US
Mailing Address - Phone:505-304-8197
Mailing Address - Fax:
Practice Address - Street 1:2001 CENTRO FAMILIAR BLVD SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-4592
Practice Address - Country:US
Practice Address - Phone:505-873-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-06
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NMSWB-2024-06911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician