Provider Demographics
NPI:1235495813
Name:LANDRY, JACOB EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:EDWARD
Last Name:LANDRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:457 HEYMANN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503
Mailing Address - Country:US
Mailing Address - Phone:337-237-5774
Mailing Address - Fax:
Practice Address - Street 1:4809 AMBASSADOR CAFFERY PKWY STE 410
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-8802
Practice Address - Country:US
Practice Address - Phone:337-470-4881
Practice Address - Fax:337-470-4882
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-08
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA304802208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery