Basic Information
| Provider Information | |||||||||
| NPI: | 1811124860 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AYDELL-HONTIVEROS | ||||||||
| FirstName: | JENISE | ||||||||
| MiddleName: | NATE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25623 MELANIE CIR | ||||||||
| Address2: | |||||||||
| City: | AMITE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704225474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8555177089 | ||||||||
| FaxNumber: | 2255299939 | ||||||||
| Practice Location | |||||||||
| Address1: | 11990 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707223210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256835292 | ||||||||
| FaxNumber: | 2256831310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2009 | ||||||||
| LastUpdateDate: | 12/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 9861 | LA | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 9861 | LA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 9861 | 01 | LA | SOCIAL WORK LICENSE NUMBER | OTHER | 2330152 | 05 | LA | MEDICAID |