Provider Demographics
NPI:1952471609
Name:SHINING STAR PROFESSIONAL SERVICES INC
Entity Type:Organization
Organization Name:SHINING STAR PROFESSIONAL SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AKEE
Authorized Official - Middle Name:LJ
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:318-795-8055
Mailing Address - Street 1:9050 YOUREE DRIVE
Mailing Address - Street 2:#1004
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115
Mailing Address - Country:US
Mailing Address - Phone:318-795-8055
Mailing Address - Fax:318-635-7100
Practice Address - Street 1:9050 YOUREE DRIVE
Practice Address - Street 2:#1004
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115
Practice Address - Country:US
Practice Address - Phone:318-795-8055
Practice Address - Fax:318-635-7100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4322104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1562904Medicaid
LA5X968OtherINDIVIDUAL MEDICARE #
LA5CQ08Medicare ID - Type UnspecifiedGROUP #
LA1562904Medicaid