Provider Demographics
NPI:1619445723
Name:JONES, CRYSTAL TRENIKA
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:TRENIKA
Last Name:JONES
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:PO BOX 1222
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:LA
Mailing Address - Zip Code:70669-1222
Mailing Address - Country:US
Mailing Address - Phone:337-707-5635
Mailing Address - Fax:
Practice Address - Street 1:1212 SALLY MAE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-1530
Practice Address - Country:US
Practice Address - Phone:337-707-5635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA008221900171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
83-2358572OtherNEMT
LA83-2358572Medicaid