Provider Demographics
NPI:1720445554
Name:ROGER, JAKE (LMSW)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:ROGER
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3229 DEBOUCHEL BLVD
Mailing Address - Street 2:
Mailing Address - City:MERAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70075-2220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3229 DEBOUCHEL BLVD
Practice Address - Street 2:
Practice Address - City:MERAUX
Practice Address - State:LA
Practice Address - Zip Code:70075-2220
Practice Address - Country:US
Practice Address - Phone:504-575-9036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12207104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker