Provider Demographics
NPI:1588357404
Name:PORTIS, LAJUANDA DAVIS (MLS)
Entity type:Individual
Prefix:MRS
First Name:LAJUANDA
Middle Name:DAVIS
Last Name:PORTIS
Suffix:
Gender:F
Credentials:MLS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4412 MANHATTAN RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-6134
Mailing Address - Country:US
Mailing Address - Phone:601-954-5847
Mailing Address - Fax:
Practice Address - Street 1:4840 MCWILLIE CIR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-5024
Practice Address - Country:US
Practice Address - Phone:601-954-5847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach