Basic Information
| Provider Information | |||||||||
| NPI: | 1104456581 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | SHAVONDA | ||||||||
| MiddleName: | RACHEL | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | CSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 JOHN WESLEY BLVD APT 171 | ||||||||
| Address2: | |||||||||
| City: | BOSSIER CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711122294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182196181 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1434 HAWN AVE STE 12 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711076508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186750224 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2020 | ||||||||
| LastUpdateDate: | 01/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | 15567 | LA | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.