Provider Demographics
NPI:1376635607
Name:JAYAKRISHNAN, CHEMMALE
Entity Type:Individual
Prefix:DR
First Name:CHEMMALE
Middle Name:
Last Name:JAYAKRISHNAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:843 MILLING AVE
Mailing Address - Street 2:
Mailing Address - City:LULING
Mailing Address - State:LA
Mailing Address - Zip Code:70070-4442
Mailing Address - Country:US
Mailing Address - Phone:985-785-5800
Mailing Address - Fax:985-785-5811
Practice Address - Street 1:1057 PAUL MAILLARD RD
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:LA
Practice Address - Zip Code:70070-4349
Practice Address - Country:US
Practice Address - Phone:985-785-2045
Practice Address - Fax:504-575-3691
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04201R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1444642Medicaid
LA1182290Medicaid
LA5K042B724Medicare ID - Type Unspecified
LA191834Medicare Oscar/Certification
LA1444642Medicaid
LA5CD42Medicare PIN