Provider Demographics
NPI:1871269951
Name:JONES, LILLIAN M
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:M
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 1:2804 EMERY ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71109-5814
Mailing Address - Country:US
Mailing Address - Phone:318-990-6420
Mailing Address - Fax:
Practice Address - Street 1:2804 EMERY ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71109-5814
Practice Address - Country:US
Practice Address - Phone:318-990-6420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA76-6000783Medicaid