Healthcare Provider Details

I. General information

NPI: 1003465998
Provider Name (Legal Business Name): JERRICA M KING BA, CIT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2019
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W VERMILION ST
LAFAYETTE LA
70501-6729
US

IV. Provider business mailing address

1333 COMMON ST
LAKE CHARLES LA
70601-5255
US

V. Phone/Fax

Practice location:
  • Phone: 337-345-6120
  • Fax:
Mailing address:
  • Phone: 337-437-4014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number5454
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: