Provider Demographics
NPI:1366656787
Name:WADDLE, JENNIFER HALEY (WHCNP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:HALEY
Last Name:WADDLE
Suffix:
Gender:F
Credentials:WHCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 BERT KOUN LOOP
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3133
Mailing Address - Country:US
Mailing Address - Phone:318-212-5790
Mailing Address - Fax:318-212-5795
Practice Address - Street 1:2508 BERT KOUN LOOP
Practice Address - Street 2:SUITE 201
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3133
Practice Address - Country:US
Practice Address - Phone:318-212-5790
Practice Address - Fax:318-212-5795
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04789363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAAP04789OtherAPRN
LARN098243OtherLICENSE---NURSING