Provider Demographics
NPI:1114583739
Name:LEBLANC, KEENON JARELL
Entity Type:Individual
Prefix:
First Name:KEENON
Middle Name:JARELL
Last Name:LEBLANC
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 1:603 W GLORIA SWITCH RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70507-2315
Mailing Address - Country:US
Mailing Address - Phone:337-706-5443
Mailing Address - Fax:
Practice Address - Street 1:603 W GLORIA SWITCH RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70507-2315
Practice Address - Country:US
Practice Address - Phone:337-706-5443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-20
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician