Provider Demographics
NPI:1063862118
Name:BERRY, JAYLON
Entity Type:Individual
Prefix:
First Name:JAYLON
Middle Name:
Last Name:BERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4609 N MARKET ST
Mailing Address - Street 2:STE. A
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-2900
Mailing Address - Country:US
Mailing Address - Phone:318-626-5462
Mailing Address - Fax:318-626-5562
Practice Address - Street 1:4609 N MARKET ST
Practice Address - Street 2:STE. A
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-2900
Practice Address - Country:US
Practice Address - Phone:318-626-5462
Practice Address - Fax:318-626-5562
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health