Provider Demographics
NPI:1508260720
Name:MIXON, JONATHAN LAMONT
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:LAMONT
Last Name:MIXON
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 1:1713 PEMBROKE ST
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70563-8616
Mailing Address - Country:US
Mailing Address - Phone:337-380-9064
Mailing Address - Fax:
Practice Address - Street 1:106 HEYMANN BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2322
Practice Address - Country:US
Practice Address - Phone:337-504-4279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-17
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08044363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health