Healthcare Provider Details

I. General information

NPI: 1063111235
Provider Name (Legal Business Name): JONATHAN W SIMMONS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 03/03/2023
Certification Date: 03/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 DIXIE PLZ
NATCHITOCHES LA
71457-5881
US

IV. Provider business mailing address

1000 CHINABERRY DR STE 900
BOSSIER CITY LA
71111-2455
US

V. Phone/Fax

Practice location:
  • Phone: 318-357-9009
  • Fax:
Mailing address:
  • Phone: 318-459-6795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: