Provider Demographics
NPI:1992901797
Name:JACQUEZ, ROBERTO PEREZ (LPCC)
Entity type:Individual
Prefix:MR
First Name:ROBERTO
Middle Name:PEREZ
Last Name:JACQUEZ
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:CHAMBERINO
Mailing Address - State:NM
Mailing Address - Zip Code:88027-0307
Mailing Address - Country:US
Mailing Address - Phone:505-644-2452
Mailing Address - Fax:
Practice Address - Street 1:515 E. LARA ROAD
Practice Address - Street 2:
Practice Address - City:CHAMBERINO
Practice Address - State:NM
Practice Address - Zip Code:88027-0307
Practice Address - Country:US
Practice Address - Phone:505-644-2452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM006091101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional