Provider Demographics
NPI:1245776756
Name:TELLIS, JERREL
Entity Type:Individual
Prefix:
First Name:JERREL
Middle Name:
Last Name:TELLIS
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 1:2715 MACKEY PL
Mailing Address - Street 2:STE 15
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-2544
Mailing Address - Country:US
Mailing Address - Phone:318-220-8423
Mailing Address - Fax:
Practice Address - Street 1:2715 MACKEY PL
Practice Address - Street 2:STE 15
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-2544
Practice Address - Country:US
Practice Address - Phone:318-220-8423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-09
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health