Healthcare Provider Details

I. General information

NPI: 1609346881
Provider Name (Legal Business Name): TRINESE JACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2018
Last Update Date: 06/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2714 CANAL ST STE 402
NEW ORLEANS LA
70119-5559
US

IV. Provider business mailing address

1540 FLOOD ST
NEW ORLEANS LA
70117-3335
US

V. Phone/Fax

Practice location:
  • Phone: 504-304-6945
  • Fax:
Mailing address:
  • Phone: 504-606-0796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: