MEDICARE: JACKIE SIMMONS MSP, CIT3407

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	CIT3407	LA

General Provider Information

NPI Number	:	1043683444
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKIE SIMMONS MSP, CIT3407

Provider Business Mailing Address
First Line	:	2274 WOODDALE BLVD
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70806-1444
Country	:	US
Telephone Number	:	225-928-1088
Fax Number	:

Provider Business Practice Location Address
First Line	:	2274 WOODDALE BLVD
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70806-1444
Country	:	US
Telephone Number	:	225-928-1088
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2015
Last Update Date	:	11/06/2015

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