Basic Information
| Provider Information | |||||||||
| NPI: | 1467918490 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | RAYNEA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 303 HICKORY ST | ||||||||
| Address2: | |||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703012011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854462936 | ||||||||
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| Practice Location | |||||||||
| Address1: | 303 HICKORY ST | ||||||||
| Address2: | |||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703012011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854462936 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2019 | ||||||||
| LastUpdateDate: | 02/14/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 1295246585 | 05 | LA | MEDICAID |