Basic Information
| Provider Information | |||||||||
| NPI: | 1629743596 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | B | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4944 S SHERWOOD FOREST BLVD APT 125 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708164615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015199106 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11408 LAKE SHERWOOD AVE N STE A | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708160421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252617143 | ||||||||
| FaxNumber: | 2252501026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2021 | ||||||||
| LastUpdateDate: | 08/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.