Provider Demographics
NPI:1770017931
Name:JACK, DEION A
Entity Type:Individual
Prefix:MR
First Name:DEION
Middle Name:A
Last Name:JACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 ST. CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:LECOMPTE
Mailing Address - State:LA
Mailing Address - Zip Code:71346
Mailing Address - Country:US
Mailing Address - Phone:318-406-3044
Mailing Address - Fax:318-406-3045
Practice Address - Street 1:2204 ST. CHARLES ST
Practice Address - Street 2:
Practice Address - City:LECOMPTE
Practice Address - State:LA
Practice Address - Zip Code:71346
Practice Address - Country:US
Practice Address - Phone:318-406-3044
Practice Address - Fax:318-406-3045
Is Sole Proprietor?:No
Enumeration Date:2017-04-14
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator