Provider Demographics
NPI:1417394560
Name:COLE, JIMMIE D (PHD)
Entity type:Individual
Prefix:DR
First Name:JIMMIE
Middle Name:D
Last Name:COLE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:JIMMIE
Other - Middle Name:DEAN
Other - Last Name:COLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:209 RIVER RANCH BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6664
Mailing Address - Country:US
Mailing Address - Phone:337-470-4532
Mailing Address - Fax:337-470-4916
Practice Address - Street 1:4801 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6917
Practice Address - Country:US
Practice Address - Phone:337-470-4532
Practice Address - Fax:337-470-4916
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA145103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1901245Medicaid
LA1901245Medicaid
LAR60966Medicare UPIN