Basic Information
| Provider Information | |||||||||
| NPI: | 1225496797 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUILLORY | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2525 YOUREE DR | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711043671 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 850 KALISTE SALOOM RD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705084230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372612300 | ||||||||
| FaxNumber: | 3372619080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2016 | ||||||||
| LastUpdateDate: | 05/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.