Provider Demographics
NPI:1265039366
Name:HAGAN, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:HAGAN
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 1:111 CHRISTIAN DR
Mailing Address - Street 2:
Mailing Address - City:RAYVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71269-3658
Mailing Address - Country:US
Mailing Address - Phone:318-728-4400
Mailing Address - Fax:318-728-4430
Practice Address - Street 1:111 CHRISTIAN DR
Practice Address - Street 2:
Practice Address - City:RAYVILLE
Practice Address - State:LA
Practice Address - Zip Code:71269-3658
Practice Address - Country:US
Practice Address - Phone:318-728-4400
Practice Address - Fax:318-728-4430
Is Sole Proprietor?:No
Enumeration Date:2020-10-02
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA213888363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily