Provider Demographics
NPI:1265014252
Name:JONES, DESHUMBRA
Entity Type:Individual
Prefix:
First Name:DESHUMBRA
Middle Name:
Last Name:JONES
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 1:1401 HUDSON LN STE 135
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-6037
Mailing Address - Country:US
Mailing Address - Phone:318-651-0086
Mailing Address - Fax:
Practice Address - Street 1:1401 HUDSON LN STE 135
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-6037
Practice Address - Country:US
Practice Address - Phone:318-651-0086
Practice Address - Fax:318-651-0087
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
No171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1780160390Medicaid