Provider Demographics
NPI:1770266215
Name:JEFFERSON, SHANIQUA MONAE (MA, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:SHANIQUA
Middle Name:MONAE
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12703
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70612-2703
Mailing Address - Country:US
Mailing Address - Phone:337-376-0136
Mailing Address - Fax:337-376-5244
Practice Address - Street 1:127 WILLIAMSBURG ST BLDG E
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5719
Practice Address - Country:US
Practice Address - Phone:337-376-0136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL-773103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst