Healthcare Provider Details

I. General information

NPI: 1114304375
Provider Name (Legal Business Name): JONATHON SOSSAMON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2015
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 W 8TH ST
DERIDDER LA
70634-5507
US

IV. Provider business mailing address

PO BOX 935
DERIDDER LA
70634-0935
US

V. Phone/Fax

Practice location:
  • Phone: 337-463-8977
  • Fax: 337-462-3093
Mailing address:
  • Phone: 337-463-8977
  • Fax: 337-462-3093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number303959
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: