Healthcare Provider Details

I. General information

NPI: 1447233036
Provider Name (Legal Business Name): JACK COLE NOBLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 01/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 W HICKORY AVE
BASTROP LA
71220-4441
US

IV. Provider business mailing address

130 DESIARD ST SUITE 355
MONROE LA
71201-7319
US

V. Phone/Fax

Practice location:
  • Phone: 318-281-4450
  • Fax: 318-281-4464
Mailing address:
  • Phone: 318-807-7875
  • Fax: 318-812-6603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number014889
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: