Healthcare Provider Details

I. General information

NPI: 1952266082
Provider Name (Legal Business Name): SHONTAE MARIE JETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2025
Last Update Date: 12/20/2025
Certification Date: 12/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6015 HEARNE AVE
SHREVEPORT LA
71108-3803
US

IV. Provider business mailing address

6015 HEARNE AVE
SHREVEPORT LA
71108-3803
US

V. Phone/Fax

Practice location:
  • Phone: 318-213-0904
  • Fax: 318-213-0905
Mailing address:
  • Phone: 318-213-0904
  • Fax: 318-213-0905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: