Provider Demographics
NPI:1154355618
Name:DANZELL, JACQUELINE A (LCSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:A
Last Name:DANZELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 PIERREMONT RD
Mailing Address - Street 2:SUITE 410
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-2056
Mailing Address - Country:US
Mailing Address - Phone:318-861-8625
Mailing Address - Fax:318-861-8626
Practice Address - Street 1:910 PIERREMONT RD
Practice Address - Street 2:SUITE 410
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-2056
Practice Address - Country:US
Practice Address - Phone:318-861-8625
Practice Address - Fax:318-861-8626
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1151831Medicaid
LA450505442OtherTAX ID NO.
LA1151831Medicaid