Provider Demographics
NPI:1750875944
Name:LARRY, JARVIS DECARLEONNE
Entity type:Individual
Prefix:MR
First Name:JARVIS
Middle Name:DECARLEONNE
Last Name:LARRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1172 PELICAN CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-8539
Mailing Address - Country:US
Mailing Address - Phone:318-617-8767
Mailing Address - Fax:
Practice Address - Street 1:1513 LINE AVE # 222
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?:No
Enumeration Date:2018-06-20
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker