Provider Demographics
NPI:1437639952
Name:TILLEY, JEANETTE (FNP-C)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:TILLEY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 MILLER RD
Mailing Address - Street 2:
Mailing Address - City:BOYCE
Mailing Address - State:LA
Mailing Address - Zip Code:71409-9838
Mailing Address - Country:US
Mailing Address - Phone:318-471-8983
Mailing Address - Fax:
Practice Address - Street 1:1585 3RD ST BLDG 285
Practice Address - Street 2:
Practice Address - City:FORT POLK
Practice Address - State:LA
Practice Address - Zip Code:71459-5102
Practice Address - Country:US
Practice Address - Phone:337-531-3751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-14
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP10133363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily