=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336019611
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOUNDATION COUNSELING, COACHING & CONSULTATIONS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2025
-----------------------------------------------------
Last Update Date | 11/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9051 MANSFIELD RD STE E11
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71118-2680
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-588-8092
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 611 E WASHINGTON ST APT 102
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71104-3729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-655-3807
-----------------------------------------------------
Fax | 318-655-3807
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | JENITA BLUE BLUE
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 318-655-3807
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------