Provider Demographics
NPI:1538520796
Name:FANGUY, LPC, JASON C
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:C
Last Name:FANGUY, LPC
Suffix:
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 1:3398 BROOKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-7297
Mailing Address - Country:US
Mailing Address - Phone:985-856-2990
Mailing Address - Fax:
Practice Address - Street 1:235 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-5937
Practice Address - Country:US
Practice Address - Phone:985-333-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-16
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
LA8752101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA8752OtherLICENSED PROFESSIONAL COUNSELOR LICENSE #8752