Provider Demographics
NPI:1578333985
Name:WILLS, JERARD LEMONE
Entity Type:Individual
Prefix:
First Name:JERARD
Middle Name:LEMONE
Last Name:WILLS
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 1:420 E TOPEKA ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-5242
Mailing Address - Country:US
Mailing Address - Phone:318-272-4965
Mailing Address - Fax:
Practice Address - Street 1:420 E TOPEKA ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-5242
Practice Address - Country:US
Practice Address - Phone:318-272-4965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA000057671172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver