Provider Demographics
NPI:1245717248
Name:JELKS, MICHAEL BRADFORD (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRADFORD
Last Name:JELKS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2421 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-2710
Mailing Address - Country:US
Mailing Address - Phone:225-654-1061
Mailing Address - Fax:225-654-0791
Practice Address - Street 1:2421 CHURCH ST
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-2710
Practice Address - Country:US
Practice Address - Phone:225-654-1061
Practice Address - Fax:225-654-0791
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1871-806AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1871-806ATOtherLA OPTOMETRY LICENSE