Healthcare Provider Details

I. General information

NPI: 1093189458
Provider Name (Legal Business Name): DWAYNE JACOBS LPC, 6090
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2015
Last Update Date: 02/25/2026
Certification Date: 02/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 W PINHOOK RD STE 107
LAFAYETTE LA
70503-3100
US

IV. Provider business mailing address

1405 W PINHOOK RD STE 107
LAFAYETTE LA
70503-3100
US

V. Phone/Fax

Practice location:
  • Phone: 337-232-9459
  • Fax:
Mailing address:
  • Phone: 337-232-9459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6090
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: