Healthcare Provider Details

I. General information

NPI: 1265093744
Provider Name (Legal Business Name): JACQUE LEE ROBINSON-RICHARD RAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 W PINHOOK RD STE 504
LAFAYETTE LA
70508-3212
US

IV. Provider business mailing address

2020 W PINHOOK RD STE 504
LAFAYETTE LA
70508-3212
US

V. Phone/Fax

Practice location:
  • Phone: 337-214-2100
  • Fax: 337-284-3559
Mailing address:
  • Phone: 337-214-2100
  • Fax: 337-284-3559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1648
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: