Healthcare Provider Details

I. General information

NPI: 1164960746
Provider Name (Legal Business Name): MR. JIMMIE THOMAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2017
Last Update Date: 02/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 HIGHWAY 80 E
MONROE LA
71203-8527
US

IV. Provider business mailing address

645 HIGHWAY 80 E
MONROE LA
71203-8527
US

V. Phone/Fax

Practice location:
  • Phone: 318-343-6966
  • Fax: 318-345-7123
Mailing address:
  • Phone: 318-343-6966
  • Fax: 318-345-7123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: