Provider Demographics
NPI:1255843801
Name:MIDDLETON, JENNIFER MICHELLE (NP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:MIDDLETON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 BUNCOMBE RD LOT 61
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129-9496
Mailing Address - Country:US
Mailing Address - Phone:318-834-8187
Mailing Address - Fax:
Practice Address - Street 1:7505 PINES RD STE 1235
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-3900
Practice Address - Country:US
Practice Address - Phone:225-932-9150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-03
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAG07170253363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology