=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811440209
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOUSE OF JACOB HEALTH SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2016
-----------------------------------------------------
Last Update Date | 08/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 316 FILMORE ST
-----------------------------------------------------
City | KENNER
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70062-7810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-305-0035
-----------------------------------------------------
Fax | 504-305-0004
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 316 FILMORE ST
-----------------------------------------------------
City | KENNER
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70062-7810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-305-0035
-----------------------------------------------------
Fax | 504-305-0004
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ESTHER CLARISSE WANDA
-----------------------------------------------------
Credential | PHARM.D.
-----------------------------------------------------
Telephone | 504-251-8477
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------