1962178053 NPI number — JESSICA L HOWARD

Table of content: JESSICA L HOWARD (NPI 1962178053)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962178053 NPI number — JESSICA L HOWARD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOWARD
Provider First Name:
JESSICA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962178053
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 CHINABERRY DR STE 903
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSSIER CITY
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71111-2455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-459-6795
Provider Business Mailing Address Fax Number:
318-626-5429

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30826 LINDER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENHAM SPRINGS
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70726-8507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-665-7878
Provider Business Practice Location Address Fax Number:
225-665-7856
Provider Enumeration Date:
08/18/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 600964601 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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