Provider Demographics
NPI:1801535265
Name:WILLIS, JOHN PAUL (PSS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:PAUL
Last Name:WILLIS
Suffix:
Gender:M
Credentials:PSS
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 640548
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70064-0548
Mailing Address - Country:US
Mailing Address - Phone:504-367-4234
Mailing Address - Fax:504-367-4237
Practice Address - Street 1:1799 STUMPF BLVD STE 2&4
Practice Address - Street 2:
Practice Address - City:TERRYTOWN
Practice Address - State:LA
Practice Address - Zip Code:70056-3950
Practice Address - Country:US
Practice Address - Phone:504-367-4234
Practice Address - Fax:504-367-4237
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOBHPSS883175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAOBHPSS883Medicaid