Healthcare Provider Details

I. General information

NPI: 1043206543
Provider Name (Legal Business Name): EAST LOUISIANA STATE HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 02/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 HIGHWAY 951
JACKSON LA
70748-0498
US

IV. Provider business mailing address

P.O. BOX 498 4502 HIGHWAY 951
JACKSON LA
70748-0498
US

V. Phone/Fax

Practice location:
  • Phone: 225-634-0533
  • Fax: 225-634-5827
Mailing address:
  • Phone: 225-634-0533
  • Fax: 225-634-5827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number201
License Number StateLA

VIII. Authorized Official

Name: MRS. MALISSA C. COLEMAN
Title or Position: ACCOUNTANT MANAGER 3
Credential: B.S.
Phone: 225-634-0533