Provider Demographics
NPI:1760193163
Name:FOUNTAINE, JARVIS (CIT)
Entity Type:Individual
Prefix:
First Name:JARVIS
Middle Name:
Last Name:FOUNTAINE
Suffix:
Gender:M
Credentials:CIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 WELWYN WAY
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-2617
Mailing Address - Country:US
Mailing Address - Phone:318-880-1289
Mailing Address - Fax:
Practice Address - Street 1:5505 SHREVEPORT HWY
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-3533
Practice Address - Country:US
Practice Address - Phone:318-441-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor