Provider Demographics
NPI:1235650417
Name:PRATER, JERMINE THERESA
Entity Type:Individual
Prefix:
First Name:JERMINE
Middle Name:THERESA
Last Name:PRATER
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:POST OFFICE BOX 450
Mailing Address - Street 2:
Mailing Address - City:MANSURA
Mailing Address - State:LA
Mailing Address - Zip Code:71350
Mailing Address - Country:US
Mailing Address - Phone:318-964-2679
Mailing Address - Fax:318-964-2683
Practice Address - Street 1:2104 CLECO STREET
Practice Address - Street 2:
Practice Address - City:MANSURA
Practice Address - State:LA
Practice Address - Zip Code:71350
Practice Address - Country:US
Practice Address - Phone:318-964-2679
Practice Address - Fax:318-964-2683
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-28
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261QM0801X
101Y00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1679507412OtherNPI
LA1544761Medicaid
LA721422495OtherTAX IDENTIFICATION