Basic Information
| Provider Information | |||||||||
| NPI: | 1265802938 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | JACQUETTA | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 429 JORDAN DR APT 1212 | ||||||||
| Address2: | |||||||||
| City: | BOSSIER CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711124079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3187711542 | ||||||||
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| Practice Location | |||||||||
| Address1: | 856 TEXAS AVE | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711013400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184296977 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2015 | ||||||||
| LastUpdateDate: | 12/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 5769 | LA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1265802938 | 05 | LA | MEDICAID |