Individual
MR. JACKIE WAYNE ETHERIDGE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
APRN, APMHNP
Contact information
Practice address
242 WEST SHAMROCK, UNIT 1, PINEVILLE, LA 71360
(318) 484-6850
Mailing address
PO BOX 7473, ALEXANDRIA, LA 71306-7473
(318) 484-6850
(318) 484-6844
Taxonomy
Speciality
Code
Description
License number
State
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
AP05657
LA
Other
Enumeration date
10/08/2009
Last updated
10/08/2009
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