Healthcare Provider Details

I. General information

NPI: 1043017809
Provider Name (Legal Business Name): JONATHAN MICHAEL HERNANDEZ LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2025
Last Update Date: 02/28/2025
Certification Date: 02/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 W 21ST AVE
COVINGTON LA
70433-7443
US

IV. Provider business mailing address

70163 4TH ST
COVINGTON LA
70433-8411
US

V. Phone/Fax

Practice location:
  • Phone: 985-502-0892
  • Fax:
Mailing address:
  • Phone: 985-502-0892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9145
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: