Provider Demographics
NPI:1144800715
Name:DEAN, JATAURIA DEPARIS SHARDAYE
Entity Type:Individual
Prefix:MISS
First Name:JATAURIA
Middle Name:DEPARIS SHARDAYE
Last Name:DEAN
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 1:121 HANNA RD
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-3180
Mailing Address - Country:US
Mailing Address - Phone:318-512-2857
Mailing Address - Fax:
Practice Address - Street 1:1610 JACKSON ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202-2030
Practice Address - Country:US
Practice Address - Phone:318-512-2857
Practice Address - Fax:318-388-4961
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1457731366Medicaid