Healthcare Provider Details

I. General information

NPI: 1053215954
Provider Name (Legal Business Name): JONAYA CROMWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 OLIVE ST
SHREVEPORT LA
71104-2103
US

IV. Provider business mailing address

925 OLIVE ST
SHREVEPORT LA
71104-2103
US

V. Phone/Fax

Practice location:
  • Phone: 318-300-3560
  • Fax: 318-300-3561
Mailing address:
  • Phone: 318-300-3560
  • Fax: 318-300-3561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberL-1169
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: