Provider Demographics
NPI:1376190074
Name:MIRMAN, JENNIFER LAUREN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LAUREN
Last Name:MIRMAN
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 1:1000 GIROD ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70113-1989
Mailing Address - Country:US
Mailing Address - Phone:973-985-9693
Mailing Address - Fax:
Practice Address - Street 1:2222 CLEARVIEW PKWY
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-2437
Practice Address - Country:US
Practice Address - Phone:504-535-4179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7018122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist