Provider Demographics
NPI:1710475561
Name:MCCLAIN, LATAVIA JENELLE
Entity Type:Individual
Prefix:
First Name:LATAVIA
Middle Name:JENELLE
Last Name:MCCLAIN
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 705
Mailing Address - Street 2:
Mailing Address - City:GRAMBLING
Mailing Address - State:LA
Mailing Address - Zip Code:71245-0705
Mailing Address - Country:US
Mailing Address - Phone:318-548-3139
Mailing Address - Fax:
Practice Address - Street 1:829 E GEORGIA AVE STE 3
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-3901
Practice Address - Country:US
Practice Address - Phone:318-242-0730
Practice Address - Fax:318-242-0750
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator