Provider Demographics
NPI:1346589843
Name:JEFF DAVIS ADDICTIVE DISORDERS CLINIC
Entity Type:Organization
Organization Name:JEFF DAVIS ADDICTIVE DISORDERS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WENDELL
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-824-8885
Mailing Address - Street 1:221 E ACADEMY AVE STE A
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70546-5331
Mailing Address - Country:US
Mailing Address - Phone:337-824-4705
Mailing Address - Fax:337-824-4827
Practice Address - Street 1:221 E ACADEMY AVE STE A
Practice Address - Street 2:
Practice Address - City:JENNINGS
Practice Address - State:LA
Practice Address - Zip Code:70546-5331
Practice Address - Country:US
Practice Address - Phone:337-824-4705
Practice Address - Fax:337-824-4827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LASA0003505251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health