Healthcare Provider Details

I. General information

NPI: 1619885514
Provider Name (Legal Business Name): JESSIE COURVILLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 BROAD ST # 213
LAKE CHARLES LA
70601-4335
US

IV. Provider business mailing address

500 BROAD ST # 213
LAKE CHARLES LA
70601-4335
US

V. Phone/Fax

Practice location:
  • Phone: 337-429-5105
  • Fax: 337-888-9853
Mailing address:
  • Phone: 337-429-5105
  • Fax: 337-888-9853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: