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General NPI Number Information
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NPI Number | 1518267889
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Entity Type | Organization
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Legal Business Name | JEANNE STREET, PHD, APPC
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Dates
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Enumeration Date | 11/02/2010
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Last Update Date | 11/02/2010
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Provider Practice Location Address
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Address Line | 610 HERNDON AVE.
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City | SHREVEPORT
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State | LA
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Zip | 71101
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Country | US
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Telephone | 318-424-3867
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Fax | 318-424-5006
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Provider Business Mailing Address
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Address Line | 610 HERNDON AVE.
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City | SHREVEPORT
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State | LA
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Zip | 71101
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Country | US
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Telephone | 318-424-3867
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Fax | 318-424-5006
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST/PRESIDENT
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Name | JEANNE STREET
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Credential | PH.D.
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Telephone | 318-424-3867
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 342
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License Number State | LA
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