Provider Demographics
NPI:1346761301
Name:JUBAN, KORI FOGG
Entity Type:Individual
Prefix:
First Name:KORI
Middle Name:FOGG
Last Name:JUBAN
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 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-765-5727
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:5000 ODONAVAN BLVD STE 404
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:LA
Practice Address - Zip Code:70785-6355
Practice Address - Country:US
Practice Address - Phone:225-369-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-29
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP09218363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner