Healthcare Provider Details

I. General information

NPI: 1003975079
Provider Name (Legal Business Name): SHREVEPORT FAMILY MEDICINE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7505 PINES ROAD SUITE 1250
SHREVEPORT LA
71129-3927
US

IV. Provider business mailing address

7505 PINES RD SUITE 1250
SHREVEPORT LA
71129-3935
US

V. Phone/Fax

Practice location:
  • Phone: 318-686-3770
  • Fax: 318-686-3838
Mailing address:
  • Phone: 318-686-3770
  • Fax: 318-686-3838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHELIA L. JACKSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 318-686-3770