Provider Demographics
NPI:1255889804
Name:JONES, TAWANNA
Entity type:Individual
Prefix:
First Name:TAWANNA
Middle Name:
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:PO BOX 854
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:71373-0854
Mailing Address - Country:US
Mailing Address - Phone:225-752-6262
Mailing Address - Fax:225-756-6221
Practice Address - Street 1:8211 SUMMA AVE STE A
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3471
Practice Address - Country:US
Practice Address - Phone:225-752-6262
Practice Address - Fax:225-756-6221
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA22037829003747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1416371Medicaid
LA1420794Medicaid
LABH0012212Medicaid
LA1416461Medicaid