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Provider Information for 1538520796


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JASON C FANGUY, LPC


Sex: Male

NPI: 1538520796
Last Updated: 2023-10-03
Certification Date: 2023-10-03

Details

NameValue
NPI1538520796
Enumeration Date2016-03-16
NPI TypeNPI-1 Individual
Sole ProprietorYES
StatusActive
Mailing Address 3398 BROOKWOOD DR
HOUMA, LA 70360-7297
United States

Phone: 985-856-2990 | Fax:
 
Primary Practice Address 235 CIVIC CENTER BLVD
HOUMA, LA 70360-5937
United States

Phone: 985-333-2020 | Fax:
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
Other (non-Medicare)LA8752Licensed Professional Counselor License #8752
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
No 101YM0800X - Counselor - Mental Health
Yes 101YP2500X - Counselor - ProfessionalLA8752