Provider Demographics
NPI:1083816854
Name:MCCANN, JENNIFER R
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:MCCANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-4863
Mailing Address - Country:US
Mailing Address - Phone:337-515-4537
Mailing Address - Fax:337-460-1348
Practice Address - Street 1:401 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-4863
Practice Address - Country:US
Practice Address - Phone:337-515-4537
Practice Address - Fax:337-460-1348
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA201272207V00000X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1093271Medicaid
TX201988701Medicaid
LA1093271Medicaid