Healthcare Provider Details

I. General information

NPI: 1154446268
Provider Name (Legal Business Name): TJBG INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 10/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 KALISTE SALOOM RD
LAFAYETTE LA
70508
US

IV. Provider business mailing address

800 KALISTE SALOOM RD
LAFAYETTE LA
70508
US

V. Phone/Fax

Practice location:
  • Phone: 337-233-2400
  • Fax: 337-232-3656
Mailing address:
  • Phone: 337-233-2400
  • Fax: 337-232-3656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3635
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number939
License Number StateLA

VIII. Authorized Official

Name: JEANA C SONNIER
Title or Position: CLINICAL SOCIAL WORKER
Credential: LCSW LMFT
Phone: 337-233-2400