Provider Demographics
NPI:1386149896
Name:KINCHEN, JERRY JR
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:
Last Name:KINCHEN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10732 S MALL DR APT 625
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-4817
Mailing Address - Country:US
Mailing Address - Phone:337-516-6663
Mailing Address - Fax:
Practice Address - Street 1:809 POLK ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:LA
Practice Address - Zip Code:71052-2452
Practice Address - Country:US
Practice Address - Phone:225-757-5845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALPC8335101YP2500X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional