Provider Demographics
NPI:1518425073
Name:KING, JEREMIAH ROGERS
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:ROGERS
Last Name:KING
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:PO BOX 899
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:LA
Mailing Address - Zip Code:71418-0899
Mailing Address - Country:US
Mailing Address - Phone:318-649-6111
Mailing Address - Fax:318-649-5094
Practice Address - Street 1:3286 OAK ST
Practice Address - Street 2:
Practice Address - City:WISNER
Practice Address - State:LA
Practice Address - Zip Code:71378
Practice Address - Country:US
Practice Address - Phone:318-724-6789
Practice Address - Fax:318-724-6788
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA203957363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily