MEDICARE: MR. IRA JEWITT B.A.

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1154784767
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. IRA JEWITT B.A.

Provider Business Mailing Address
First Line	:	3084 WESTFORK DR
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70816-2254
Country	:	US
Telephone Number	:	225-296-6083
Fax Number	:	225-296-6082

Provider Business Practice Location Address
First Line	:	3084 WESTFORK DR
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70816-2254
Country	:	US
Telephone Number	:	225-296-6083
Fax Number	:	225-296-6082

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

Provider Enumeration Date	:	03/31/2016
Last Update Date	:	11/21/2016

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