Healthcare Provider Details

I. General information

NPI: 1922473099
Provider Name (Legal Business Name): MYLECKA SHAY JEFFERSON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2015
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11616 SOUTHFORK AVE STE 403
BATON ROUGE LA
70816-5241
US

IV. Provider business mailing address

1202 MONROE ST
GRETNA LA
70053-2307
US

V. Phone/Fax

Practice location:
  • Phone: 225-261-7143
  • Fax: 225-250-1026
Mailing address:
  • Phone: 504-309-6798
  • Fax: 504-407-2115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number9398
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number9398
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: