Provider Demographics
NPI:1831912450
Name:JACK, MANDRELL MONTEL
Entity type:Individual
Prefix:
First Name:MANDRELL
Middle Name:MONTEL
Last Name:JACK
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 1:646 S GAYOSO ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-7249
Mailing Address - Country:US
Mailing Address - Phone:504-666-2016
Mailing Address - Fax:
Practice Address - Street 1:646 S GAYOSO ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-7249
Practice Address - Country:US
Practice Address - Phone:504-666-2016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-02
Last Update Date:2024-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA300248376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide