Provider Demographics
NPI:1417308594
Name:MACK, JESSE TYLER (LPC)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:TYLER
Last Name:MACK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:JESSE
Other - Middle Name:
Other - Last Name:MACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 395
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70722-0395
Mailing Address - Country:US
Mailing Address - Phone:225-683-5292
Mailing Address - Fax:225-683-1310
Practice Address - Street 1:11990 JACKSON ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:LA
Practice Address - Zip Code:70722
Practice Address - Country:US
Practice Address - Phone:225-683-5292
Practice Address - Fax:225-683-1310
Is Sole Proprietor?:No
Enumeration Date:2016-06-29
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
LA171M00000X
LA6784101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA6784OtherSTATE OF LOUISIANA LICENSED PROFESSIONAL COUNSELORS BOARD OF EXAMINERS