Provider Demographics
NPI:1275885071
Name:WILLIFORD, JENNA ELIZABETH PENTECOST (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:ELIZABETH PENTECOST
Last Name:WILLIFORD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3802 PRESCOTT RD.
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301
Mailing Address - Country:US
Mailing Address - Phone:318-487-6060
Mailing Address - Fax:318-487-0406
Practice Address - Street 1:3802 PRESCOTT RD.
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301
Practice Address - Country:US
Practice Address - Phone:318-487-6060
Practice Address - Fax:318-487-0406
Is Sole Proprietor?:No
Enumeration Date:2012-10-04
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200555363A00000X
LAPA 200555363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical