Provider Demographics
NPI:1912917741
Name:PONDER, JACOB RANDALL (LOTR)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:RANDALL
Last Name:PONDER
Suffix:
Gender:M
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 FIDDLERS CREEK DR
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-1769
Mailing Address - Country:US
Mailing Address - Phone:318-397-9796
Mailing Address - Fax:
Practice Address - Street 1:307 REGISTER ST
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-2737
Practice Address - Country:US
Practice Address - Phone:318-329-8998
Practice Address - Fax:318-329-8997
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.Z12342225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist