Basic Information
| Provider Information | |||||||||
| NPI: | 1265014252 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | DESHUMBRA | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 HUDSON LN STE 135 | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712016037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186510086 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1401 HUDSON LN STE 135 | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712016037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186510086 | ||||||||
| FaxNumber: | 3186510087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2021 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171W00000X | LA | N | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Contractor |
ID Information
| ID | Type | State | Issuer | Description | 1780160390 | 05 | LA | MEDICAID |