Provider Demographics
NPI:1629645130
Name:MARICLE, JAELYN
Entity Type:Individual
Prefix:MISS
First Name:JAELYN
Middle Name:
Last Name:MARICLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BROWN DOYLE RD
Mailing Address - Street 2:
Mailing Address - City:PITKIN
Mailing Address - State:LA
Mailing Address - Zip Code:70656-2004
Mailing Address - Country:US
Mailing Address - Phone:318-452-1717
Mailing Address - Fax:
Practice Address - Street 1:1500 LEE ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-6234
Practice Address - Country:US
Practice Address - Phone:318-625-7050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA011331500171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA011331500Medicaid