Provider Demographics
NPI:1750972667
Name:BARRERA, KASSANDRA
Entity type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:
Last Name:BARRERA
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 1:2745 COTTAGE STREET
Mailing Address - Street 2:1038
Mailing Address - City:JACKSON
Mailing Address - State:LA
Mailing Address - Zip Code:70748
Mailing Address - Country:US
Mailing Address - Phone:225-245-2257
Mailing Address - Fax:225-351-9033
Practice Address - Street 1:2745 COTTAGE STREET
Practice Address - Street 2:1038
Practice Address - City:JACKSON
Practice Address - State:LA
Practice Address - Zip Code:70748
Practice Address - Country:US
Practice Address - Phone:225-245-2257
Practice Address - Fax:225-351-9033
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA861509583172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA86-1509583Medicaid