Provider Demographics
NPI:1083815583
Name:JACQUES, CHARLES G III (LPC, LMT, LMFT)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:G
Last Name:JACQUES
Suffix:III
Gender:M
Credentials:LPC, LMT, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8017 JEFFERSON HWY STE A3
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-1681
Mailing Address - Country:US
Mailing Address - Phone:225-924-4903
Mailing Address - Fax:
Practice Address - Street 1:8017 JEFFERSON HWY STE A3
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-1681
Practice Address - Country:US
Practice Address - Phone:225-924-4903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health