Provider Demographics
NPI:1558869396
Name:ROSSUM, JOSEPH AARON (MHS)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:AARON
Last Name:ROSSUM
Suffix:
Gender:M
Credentials:MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7442 WATERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:LA
Mailing Address - Zip Code:71033-3366
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9403 MANSFIELD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118
Practice Address - Country:US
Practice Address - Phone:318-603-4396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1760852511OtherLOUISIANA HEALTH CONECTION
LA1760852511OtherFUNCTION FAMILY THERAPY
LA1760852511OtherAMERIGROUP
LA1760852511Medicaid
LA1760852511OtherAMERICARE
LA1760852511OtherAETNA