Provider Demographics
NPI:1023713211
Name:BANKS, JOHNETTA PATRICE
Entity type:Individual
Prefix:DR
First Name:JOHNETTA
Middle Name:PATRICE
Last Name:BANKS
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 1:147 DOGWOOD SOUTH LN
Mailing Address - Street 2:
Mailing Address - City:HAUGHTON
Mailing Address - State:LA
Mailing Address - Zip Code:71037-7522
Mailing Address - Country:US
Mailing Address - Phone:318-267-6677
Mailing Address - Fax:
Practice Address - Street 1:1513 LINE AVENUE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101
Practice Address - Country:US
Practice Address - Phone:318-208-8908
Practice Address - Fax:318-208-8935
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health