Provider Demographics
NPI:1417013574
Name:MENDOZA, JACQUELINE K (LCSW, ACSW,LCDC (TX))
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:K
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:LCSW, ACSW,LCDC (TX)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 S EUGENE ST
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-5478
Mailing Address - Country:US
Mailing Address - Phone:225-931-9981
Mailing Address - Fax:
Practice Address - Street 1:4615 GOVERNMENT ST BLDG 1
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-5922
Practice Address - Country:US
Practice Address - Phone:225-922-0478
Practice Address - Fax:225-922-2658
Is Sole Proprietor?:No
Enumeration Date:2006-12-30
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9979101YA0400X
TX0189101YA0400X
TX320841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2195773OtherFIRST HEALTH NETWORK
TX258450000OtherMAGELLAN HEALTH SERVICES
TX0079KXOtherBLUE CROSS BLUE SHIELD
TX2230312OtherCIGNA
TX309302OtherMHN
TX258450000OtherMAGELLAN HEALTH SERVICES