Healthcare Provider Details

I. General information

NPI: 1578554853
Provider Name (Legal Business Name): MMO JENNINGS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 01/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 NORTH BOULEVARD
BATON ROUGE LA
70802-5724
US

IV. Provider business mailing address

619 N MAIN ST
JENNINGS LA
70546-5347
US

V. Phone/Fax

Practice location:
  • Phone: 225-293-6774
  • Fax: 225-291-9229
Mailing address:
  • Phone: 337-824-4300
  • Fax: 337-824-4315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number7858
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT L MILLER
Title or Position: CEO
Credential:
Phone: 225-293-6774