Healthcare Provider Details

I. General information

NPI: 1285461087
Provider Name (Legal Business Name): YESSICA OLGA ROQUE CERTIFIED SW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2024
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 DULLES DR
LAFAYETTE LA
70506-3008
US

IV. Provider business mailing address

1333 COMMON ST
LAKE CHARLES LA
70601-5255
US

V. Phone/Fax

Practice location:
  • Phone: 337-262-4100
  • Fax: 337-262-1146
Mailing address:
  • Phone: 337-437-4014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number18753
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number18753
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: