Basic Information
| Provider Information | |||||||||
| NPI: | 1154747327 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JEFFCARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | JEFFCARE WEST JEFFERSON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| 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: | 5001 WESTBANK EXPY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MARRERO | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700722954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5043498833 | ||||||||
| FaxNumber: | 5048385714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2014 | ||||||||
| LastUpdateDate: | 02/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DICHIRO DERBES | ||||||||
| AuthorizedOfficialFirstName: | ROSANNA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5048385215 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JEFFERSON PARISH HUMAN SERVICES AUTHORITY | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PSY.D | ||||||||
| NPICertificationDate: | 02/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 2369393 | 05 | LA | MEDICAID |