Provider Demographics
NPI:1619635497
Name:BURRELL-LOTT, JAKITHA ANTIONETTE
Entity Type:Individual
Prefix:
First Name:JAKITHA
Middle Name:ANTIONETTE
Last Name:BURRELL-LOTT
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 1:9543 LEASIDE WAY
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-4310
Mailing Address - Country:US
Mailing Address - Phone:318-461-1414
Mailing Address - Fax:
Practice Address - Street 1:9543 LEASIDE WAY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-4310
Practice Address - Country:US
Practice Address - Phone:318-461-1414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA008633137347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker