Provider Demographics
NPI:1104464411
Name:SORRELLS, JON DAVID (HIS)
Entity type:Individual
Prefix:
First Name:JON DAVID
Middle Name:
Last Name:SORRELLS
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 DR MICHAEL DEBAKEY DR STE 104
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5700
Mailing Address - Country:US
Mailing Address - Phone:337-436-3277
Mailing Address - Fax:337-439-3051
Practice Address - Street 1:2626 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5912
Practice Address - Country:US
Practice Address - Phone:337-240-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-17
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1305237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist