Healthcare Provider Details

I. General information

NPI: 1811124860
Provider Name (Legal Business Name): JENISE NATE AYDELL-HONTIVEROS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2009
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11990 JACKSON ST
CLINTON LA
70722-3210
US

IV. Provider business mailing address

25623 MELANIE CIR
AMITE LA
70422-5474
US

V. Phone/Fax

Practice location:
  • Phone: 225-683-5292
  • Fax: 225-683-1310
Mailing address:
  • Phone: 855-517-7089
  • Fax: 225-529-9939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number9861
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9861
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: