Healthcare Provider Details

I. General information

NPI: 1003345810
Provider Name (Legal Business Name): LAJERRICK D. TAYLOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 05/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 ST. CHARLES ST SUITE 101/102
LECOMPTE LA
71346
US

IV. Provider business mailing address

PO BOX 111
LECOMPTE LA
71346-0111
US

V. Phone/Fax

Practice location:
  • Phone: 318-406-3044
  • Fax: 318-406-3045
Mailing address:
  • Phone: 318-406-3044
  • Fax: 318-406-3045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: