Provider Demographics
NPI:1205022647
Name:JCT MEDICAL CONSULTING
Entity type:Organization
Organization Name:JCT MEDICAL CONSULTING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:W
Authorized Official - Last Name:TYNES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-212-1610
Mailing Address - Street 1:460 ASHLEY RIDGE BLVD STE 500
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-7228
Mailing Address - Country:US
Mailing Address - Phone:318-212-1610
Mailing Address - Fax:866-455-7515
Practice Address - Street 1:460 ASHLEY RIDGE BLVD STE 500
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-7228
Practice Address - Country:US
Practice Address - Phone:318-212-1610
Practice Address - Fax:866-455-7515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA016884261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1351661Medicaid
LA1205022647Medicare PIN