Provider Demographics
NPI:1083000384
Name:PETRY, JESSICA (MD)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:PETRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 ENERGY PARKWAY
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3816
Mailing Address - Country:US
Mailing Address - Phone:337-504-3335
Mailing Address - Fax:337-504-4795
Practice Address - Street 1:206 ENERGY PARKWAY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-3816
Practice Address - Country:US
Practice Address - Phone:337-504-3335
Practice Address - Fax:337-504-4795
Is Sole Proprietor?:No
Enumeration Date:2015-04-13
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA303881207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2390732Medicaid