Provider Demographics
NPI:1972652477
Name:PACHECO, JESSE DON (MBS, LPCS)
Entity type:Individual
Prefix:MR
First Name:JESSE
Middle Name:DON
Last Name:PACHECO
Suffix:
Gender:M
Credentials:MBS, LPCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4387 W BOGGY DEPOT RD
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74525-5472
Mailing Address - Country:US
Mailing Address - Phone:580-387-9383
Mailing Address - Fax:
Practice Address - Street 1:4387 W BOGGY DEPOT RD
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:OK
Practice Address - Zip Code:74525-5472
Practice Address - Country:US
Practice Address - Phone:580-387-9383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4063101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100699600CMedicaid