Provider Demographics
NPI:1609043017
Name:CLAIBORNE, JEREMY (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:CLAIBORNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 E STONER AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4243
Mailing Address - Country:US
Mailing Address - Phone:870-779-2750
Mailing Address - Fax:
Practice Address - Street 1:510 E. STONER AVENUE
Practice Address - Street 2:OVERTON BROOKS VA MEDICAL CENTER
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101
Practice Address - Country:US
Practice Address - Phone:318-990-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2046922084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1053732Medicaid
LAP01158547OtherRAILROAD MEDICARE
MS01733393OtherMS MEDICAID
LA4R117OtherMEDICARE PTAN