Basic Information
| Provider Information | |||||||||
| NPI: | 1003004359 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALDILLEZ | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 S MAIN ST | ||||||||
| Address2: | STE 249 | ||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880011206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055275823 | ||||||||
| FaxNumber: | 5055275886 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 OAK ST | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880053425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753233354 | ||||||||
| FaxNumber: | 5755233354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2007 | ||||||||
| LastUpdateDate: | 04/21/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TS0200X | 275299 | NM | Y | Behavioral Health & Social Service Providers | Psychologist | School |
No ID Information.