Provider Demographics
NPI:1821536806
Name:MAILLOUX JENSEN, REGINA (LAC, NCC)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:MAILLOUX JENSEN
Suffix:
Gender:F
Credentials:LAC, NCC
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:GILLESPIE
Other - Last Name:MAILLOUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC, LPC, NCC
Mailing Address - Street 1:400 MARINERS PLAZA DR
Mailing Address - Street 2:SUITE 408F
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448
Mailing Address - Country:US
Mailing Address - Phone:958-718-4507
Mailing Address - Fax:504-617-7878
Practice Address - Street 1:400 MARINERS PLAZA DR STE 408F
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-4797
Practice Address - Country:US
Practice Address - Phone:958-718-4507
Practice Address - Fax:504-617-7878
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-09
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1574101YA0400X, 251S00000X
GA8651101YM0800X
LA8517101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA81-2765138OtherIRS