Provider Demographics
NPI:1518267889
Name:JEANNE STREET, PHD, APPC
Entity Type:Organization
Organization Name:JEANNE STREET, PHD, APPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:STREET
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:318-424-3867
Mailing Address - Street 1:610 HERNDON AVE.
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101
Mailing Address - Country:US
Mailing Address - Phone:318-424-3867
Mailing Address - Fax:318-424-5006
Practice Address - Street 1:610 HERNDON AVE.
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101
Practice Address - Country:US
Practice Address - Phone:318-424-3867
Practice Address - Fax:318-424-5006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA342103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1105961Medicaid