Basic Information
| Provider Information | |||||||||
| NPI: | 1982056370 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANTRELL | ||||||||
| FirstName: | JEANNIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MCD, CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 469 SHENANDOAH DR | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711153741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182188928 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2522 E 70TH ST | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711054002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3187953388 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2016 | ||||||||
| LastUpdateDate: | 07/08/2016 | ||||||||
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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 | 235Z00000X | 4098 | LA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.