Provider Demographics
NPI:1093213217
Name:SANDERS, JEREMY BERNARD (APRN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:BERNARD
Last Name:SANDERS
Suffix:
Gender:M
Credentials:APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 LAKE ST # 6781
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-6500
Mailing Address - Country:US
Mailing Address - Phone:337-660-8918
Mailing Address - Fax:337-433-3013
Practice Address - Street 1:314 W HALE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601
Practice Address - Country:US
Practice Address - Phone:337-660-8918
Practice Address - Fax:337-433-3013
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-23
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP097992084P0005X, 2084P0804X, 2084P0805X, 2084P0800X, 2084P0802X
LARN1287432084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No2084P0005XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurodevelopmental DisabilitiesGroup - Single Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Single Specialty