Provider Demographics
NPI:1629047402
Name:VINES, JENNIFER ROGERS (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROGERS
Last Name:VINES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 W SAINT MARY BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-3568
Mailing Address - Country:US
Mailing Address - Phone:337-235-5088
Mailing Address - Fax:337-261-1152
Practice Address - Street 1:601 W SAINT MARY BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-3568
Practice Address - Country:US
Practice Address - Phone:337-235-5088
Practice Address - Fax:337-261-1152
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101YM0800X101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1336335Medicaid
LA5CH74Medicare ID - Type Unspecified