Basic Information
| Provider Information | |||||||||
| NPI: | 1043258007 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JEFFERSON PARISH HUMAN SERVICES AUTHORITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JEFFERSON PARISH HUMAN SERVICES AUTHORITY (ELMWOOD) | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3616 S I 10 SERVICE RD W STE 200 | ||||||||
| Address2: | |||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700011874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048385215 | ||||||||
| FaxNumber: | 5048385714 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 RIVER OAKS ROAD W. | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701232163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048466901 | ||||||||
| FaxNumber: | 5048385714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 02/15/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DICHIRO DERBES | ||||||||
| AuthorizedOfficialFirstName: | ROSANNA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5048385215 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | PSY.D | ||||||||
| NPICertificationDate: | 02/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 1986691 | 05 | LA | MEDICAID |