Provider Demographics
NPI:1164821088
Name:JEANE, CRISTA
Entity Type:Individual
Prefix:
First Name:CRISTA
Middle Name:
Last Name:JEANE
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 1:2204 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446-5318
Mailing Address - Country:US
Mailing Address - Phone:337-238-9305
Mailing Address - Fax:337-238-9323
Practice Address - Street 1:2204 S 5TH ST
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-5318
Practice Address - Country:US
Practice Address - Phone:337-238-9305
Practice Address - Fax:337-238-9323
Is Sole Proprietor?:No
Enumeration Date:2014-08-15
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16208183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist