Provider Demographics
NPI:1912448242
Name:SELLERS, JACOB DEMARY (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:DEMARY
Last Name:SELLERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 HEYMANN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2616
Mailing Address - Country:US
Mailing Address - Phone:337-234-1111
Mailing Address - Fax:337-234-2145
Practice Address - Street 1:427 HEYMANN BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2616
Practice Address - Country:US
Practice Address - Phone:337-234-1111
Practice Address - Fax:337-234-2145
Is Sole Proprietor?:No
Enumeration Date:2017-03-20
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA322597207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2441264Medicaid