Healthcare Provider Details

I. General information

NPI: 1164993085
Provider Name (Legal Business Name): MS. JENEA RONIQUE FREDERICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 W PINHOOK RD
LAFAYETTE LA
70508-3290
US

IV. Provider business mailing address

816 LENA DR
BREAUX BRIDGE LA
70517-6122
US

V. Phone/Fax

Practice location:
  • Phone: 337-261-8781
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPLC11307
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: