Healthcare Provider Details

I. General information

NPI: 1558138628
Provider Name (Legal Business Name): JACOB P DEPRIMO LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2023
Last Update Date: 12/08/2023
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 E ASCENSION COMPLEX BLVD
GONZALES LA
70737-4263
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 225-743-2445
  • Fax: 225-450-1150
Mailing address:
  • Phone: 225-743-2445
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11750
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: