Provider Demographics
NPI:1114002698
Name:JEANSONNE, HERNDON MARTIN II (APRN)
Entity Type:Individual
Prefix:MR
First Name:HERNDON
Middle Name:MARTIN
Last Name:JEANSONNE
Suffix:II
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:COTTONPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71327-3403
Mailing Address - Country:US
Mailing Address - Phone:318-876-3696
Mailing Address - Fax:318-876-3211
Practice Address - Street 1:1007 SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:COTTONPORT
Practice Address - State:LA
Practice Address - Zip Code:71327-3403
Practice Address - Country:US
Practice Address - Phone:318-876-3696
Practice Address - Fax:318-876-3211
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAPO4678363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1448575Medicaid
LA1306371Medicare ID - Type Unspecified