Provider Demographics
NPI:1700335155
Name:WILSON, JOLONDRA SHEREE
Entity Type:Individual
Prefix:
First Name:JOLONDRA
Middle Name:SHEREE
Last Name:WILSON
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 1:111 MARX ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71202-3417
Mailing Address - Country:US
Mailing Address - Phone:318-600-6978
Mailing Address - Fax:318-600-6978
Practice Address - Street 1:111 MARX ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202-3417
Practice Address - Country:US
Practice Address - Phone:318-600-6978
Practice Address - Fax:318-600-6978
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA008495845343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA100000271280Medicaid