Basic Information
| Provider Information | |||||||||
| NPI: | 1558488460 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIEGO-MEDINA | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DIEGO | ||||||||
| OtherFirstName: | JACQUELINE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 294 MOUNTAIN VISTA RD. | ||||||||
| Address2: | |||||||||
| City: | LA UNION | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9152524174 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5001 N PIEDRAS ST | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799304210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155646100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2007 | ||||||||
| LastUpdateDate: | 01/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 41732 | TX | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | M-05991 | NM | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 41732 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.