Provider Demographics
NPI:1396295564
Name:MACIAS, JESUS JR (CG60693090)
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:MACIAS
Suffix:JR
Gender:M
Credentials:CG60693090
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 W 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:TOPPENISH
Mailing Address - State:WA
Mailing Address - Zip Code:98948-1564
Mailing Address - Country:US
Mailing Address - Phone:509-865-3127
Mailing Address - Fax:
Practice Address - Street 1:510 W 1ST AVE
Practice Address - Street 2:
Practice Address - City:TOPPENISH
Practice Address - State:WA
Practice Address - Zip Code:98948-1564
Practice Address - Country:US
Practice Address - Phone:509-865-3127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-11
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X, 101Y00000X, 175T00000X
WACG60693090101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No175T00000XOther Service ProvidersPeer Specialist
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor