Healthcare Provider Details

I. General information

NPI: 1407513567
Provider Name (Legal Business Name): JERRIE MILES BOOKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2021
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13910 ALBA DR
BAKER LA
70714-4616
US

IV. Provider business mailing address

9403 MANSFIELD RD
SHREVEPORT LA
71118-3815
US

V. Phone/Fax

Practice location:
  • Phone: 225-931-0630
  • Fax:
Mailing address:
  • Phone: 318-861-8938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1365
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: