Provider Demographics
NPI:1144743600
Name:BRIDGES, SHANEQUA DEJON
Entity Type:Individual
Prefix:
First Name:SHANEQUA
Middle Name:DEJON
Last Name:BRIDGES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANEQUA
Other - Middle Name:DEJON
Other - Last Name:BRIDGES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PLPC
Mailing Address - Street 1:336 HIGHWAY 583 N
Mailing Address - Street 2:
Mailing Address - City:TYLERTOWN
Mailing Address - State:MS
Mailing Address - Zip Code:39667-6703
Mailing Address - Country:US
Mailing Address - Phone:601-303-5767
Mailing Address - Fax:
Practice Address - Street 1:9403 MANSFIELD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3815
Practice Address - Country:US
Practice Address - Phone:318-861-8938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-17
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional