Basic Information
| Provider Information | |||||||||
| NPI: | 1790298594 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COBB | ||||||||
| FirstName: | ALVERA | ||||||||
| MiddleName: | VERDIE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JACKSON | ||||||||
| OtherFirstName: | ALVERA | ||||||||
| OtherMiddleName: | VERDIE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1513 LINE AVENUE | ||||||||
| Address2: | 225 | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3187543890 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1513 LINE AVENUE | ||||||||
| Address2: | 225 | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3187543890 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2017 | ||||||||
| LastUpdateDate: | 12/13/2018 | ||||||||
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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 | 1041C0700X | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.