Provider Demographics
NPI:1164925426
Name:JACKSON, VALERIE PERRAULT (FNP)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:PERRAULT
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 BENTWATER DR
Mailing Address - Street 2:
Mailing Address - City:BROUSSARD
Mailing Address - State:LA
Mailing Address - Zip Code:70518-4571
Mailing Address - Country:US
Mailing Address - Phone:225-718-5319
Mailing Address - Fax:
Practice Address - Street 1:427 HEYMANN BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2616
Practice Address - Country:US
Practice Address - Phone:337-234-1111
Practice Address - Fax:337-264-1320
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN141287163WM0705X
LAAP09737363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical