Provider Demographics
NPI:1235393018
Name:ORTEGO, JENNA TRAYLOR (MMSC, PA)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:TRAYLOR
Last Name:ORTEGO
Suffix:
Gender:F
Credentials:MMSC, PA
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:NICOLE
Other - Last Name:TRAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MMSC, PA
Mailing Address - Street 1:8230 SUMMA AVE STE C
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3465
Mailing Address - Country:US
Mailing Address - Phone:225-757-0552
Mailing Address - Fax:225-763-9997
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-765-7163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200192363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1190268Medicaid
LA5CQ60PA11Medicare PIN