Provider Demographics
NPI:1548774797
Name:MOTON, JACQUILLA STEPHENS
Entity Type:Individual
Prefix:
First Name:JACQUILLA
Middle Name:STEPHENS
Last Name:MOTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 N MARKET ST STE C104
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-6545
Mailing Address - Country:US
Mailing Address - Phone:318-626-5597
Mailing Address - Fax:318-626-5691
Practice Address - Street 1:1500 N MARKET ST STE C104
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107
Practice Address - Country:US
Practice Address - Phone:318-626-5597
Practice Address - Fax:318-626-5691
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-27
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health