Healthcare Provider Details

I. General information

NPI: 1184553034
Provider Name (Legal Business Name): IESHA MARIE HARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11990 JACKSON ST
CLINTON LA
70722-3210
US

IV. Provider business mailing address

2547 MIDDLETOWNE DR
ZACHARY LA
70791-2873
US

V. Phone/Fax

Practice location:
  • Phone: 225-683-5292
  • Fax:
Mailing address:
  • Phone: 225-480-8471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number157020
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: