Provider Demographics
NPI:1417361346
Name:COBB, JEREMY
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:COBB
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 1:900 JOHNSON RD
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-8649
Mailing Address - Country:US
Mailing Address - Phone:318-537-0034
Mailing Address - Fax:318-396-1941
Practice Address - Street 1:903 WARREN DR STE C
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-7158
Practice Address - Country:US
Practice Address - Phone:318-396-1985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-18
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA18035183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist