Provider Demographics
NPI:1477190940
Name:JIRON, JACOLBY CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:JACOLBY
Middle Name:CHRISTOPHER
Last Name:JIRON
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 1:119 W VINE ST
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-5153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:119 W VINE ST
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-5153
Practice Address - Country:US
Practice Address - Phone:337-326-4568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-04
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA000000000Medicaid