Provider Demographics
NPI:1194563551
Name:PAYAN CHACON, JESUS ADALBERTO (LAPC)
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:ADALBERTO
Last Name:PAYAN CHACON
Suffix:
Gender:M
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4407
Mailing Address - Country:US
Mailing Address - Phone:701-751-0443
Mailing Address - Fax:
Practice Address - Street 1:515 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4407
Practice Address - Country:US
Practice Address - Phone:701-751-0443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1376-7-1-24A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health