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NPI Code Detail

MEDICARE: JERRY PICKENS M.A.

MEDICARE: JERRY PICKENS M.A.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1390200000XStudent in an Organized Health Care Education/Training Program
2171M00000XCase Manager/Care Coordinator

General Provider Information

NPI Number : 1740625060
Entity Type Code : Individual
Provider Name (Legal Business Name) : JERRY PICKENS M.A.
Provider Business Mailing Address
First Line : 411 SUMMIT ST
Second Line :
City : MINDEN
State : LA
Zip : 71055-2837
Country : US
Telephone Number : 313-718-8829
Fax Number :
Provider Business Practice Location Address
First Line : 9403 MANSFIELD RD
Second Line :
City : SHREVEPORT
State : LA
Zip : 71118-3815
Country : US
Telephone Number : 318-861-8938
Fax Number : 318-862-3554
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/30/2013
Last Update Date : 06/03/2020

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