Active NPI
Jacob Wade Funderburk, PLPC
- Professional Counselor
- Shreveport, LA
National Provider Identifier
1639749617
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Professional Counselor
- License
- 8671
- Practice address
- 6240 Greenwood Rd
Shreveport, LA 71119-8413 - Phone
- (318) 562-6320
- NPI assigned
- Jun 30, 2021
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Professional Counselor | 101YP2500X | 8671 | LA | Primary |
Addresses
Primary practice location
6240 Greenwood Rd
Shreveport, LA 71119-8413
Mailing address
652 Prospect St
Shreveport, LA 71104-3124
Phone (318) 508-1301
Other practice location 1
2984 Old Plain Dealing Rd
Plain Dealing, LA 71064-4320
Phone (318) 508-1301
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 8671 | LA | MD | Professional Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1625011200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1730851200000",
"number": "1639749617",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "652 PROSPECT ST",
"city": "SHREVEPORT",
"state": "LA",
"postal_code": "711043124",
"telephone_number": "318-508-1301"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "6240 GREENWOOD RD",
"city": "SHREVEPORT",
"state": "LA",
"postal_code": "711198413",
"telephone_number": "318-562-6320"
}
],
"practiceLocations": [
{
"address_1": "2984 Old Plain Dealing Rd",
"address_purpose": "LOCATION",
"city": "Plain Dealing",
"state": "LA",
"postal_code": "710644320",
"country_code": "US",
"telephone_number": "318-508-1301",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "FUNDERBURK",
"first_name": "JACOB",
"middle_name": "WADE",
"credential": "PLPC",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2021-06-30",
"last_updated": "2024-11-06",
"certification_date": "2024-11-06",
"status": "A"
},
"taxonomies": [
{
"code": "101YP2500X",
"taxonomy_group": "",
"desc": "Counselor, Professional",
"state": "LA",
"license": "8671",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Shreveport, LA
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- Christopher Fultz, DPT
- Function First Physical Therapy, LLC
- Dannette Furgerson, AGPCNP
- Ansley Fussell, MOT
- Zachary Blake Fussell, MSN, APRN, PMHNP-BC
- Michael Futrell, MD
- G Brent Whitton MD and Willis-Knighton Medical Center
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 6, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.