Provider Demographics
NPI:1427674894
Name:STEWART, JAQUALA
Entity type:Individual
Prefix:
First Name:JAQUALA
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 THOMAS H DELPIT DR STE 126
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70802-6626
Mailing Address - Country:US
Mailing Address - Phone:225-636-2395
Mailing Address - Fax:
Practice Address - Street 1:1520 THOMAS H DELPIT DR STE 126
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70802-6626
Practice Address - Country:US
Practice Address - Phone:225-636-2395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA011727522103K00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst