Healthcare Provider Details

I. General information

NPI: 1023467305
Provider Name (Legal Business Name): JACQUELINE MCMILLAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 06/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 FELICIA AVE
TALLULAH LA
71282-8203
US

IV. Provider business mailing address

1705 FELICIA AVE
TALLULAH LA
71282-8203
US

V. Phone/Fax

Practice location:
  • Phone: 318-574-1232
  • Fax: 318-574-8646
Mailing address:
  • Phone: 318-574-1232
  • Fax: 318-574-8646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: