Provider Demographics
NPI:1760293476
Name:CAPTVILLE, JAMARCUS KEON SR
Entity type:Individual
Prefix:MR
First Name:JAMARCUS
Middle Name:KEON
Last Name:CAPTVILLE
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 MONTERREY BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70815-1155
Mailing Address - Country:US
Mailing Address - Phone:225-877-8566
Mailing Address - Fax:
Practice Address - Street 1:433 WINTER ST
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-6607
Practice Address - Country:US
Practice Address - Phone:225-877-8566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-14
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1386450104Medicaid
LA1386450104Medicaid