Provider Demographics
NPI:1043891526
Name:MIRANDA, JESSICA TERESA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:TERESA
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8326 KELWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-4803
Mailing Address - Country:US
Mailing Address - Phone:318-473-4328
Mailing Address - Fax:
Practice Address - Street 1:1403 METRO DR STE C1
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3446
Practice Address - Country:US
Practice Address - Phone:318-625-7467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-16
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X, 175T00000X
175T00000X
LA18010101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker