Basic Information
| Provider Information | |||||||||
| NPI: | 1235856162 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VILLANUEBA | ||||||||
| FirstName: | JESSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1328 | ||||||||
| Address2: | |||||||||
| City: | DURANGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813021328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702592162 | ||||||||
| FaxNumber: | 9703352447 | ||||||||
| Practice Location | |||||||||
| Address1: | 281 SAWYER DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | DURANGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813033409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702592162 | ||||||||
| FaxNumber: | 9703352447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2022 | ||||||||
| LastUpdateDate: | 10/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LSW.0009924378 | CO | N | Behavioral Health & Social Service Providers | Social Worker | 101YA0400X | ACD.0002096 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.