Provider Demographics
NPI:1447752100
Name:JESSICA PETRY, M.D. A.P.M.C.
Entity Type:Organization
Organization Name:JESSICA PETRY, M.D. A.P.M.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAULLIEU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-504-3335
Mailing Address - Street 1:4809 AMBASSADOR CAFFERY PKWY STE 410
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-8802
Mailing Address - Country:US
Mailing Address - Phone:337-504-3335
Mailing Address - Fax:337-504-4795
Practice Address - Street 1:4809 AMBASSADOR CAFFERY PKWY STE 410
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508
Practice Address - Country:US
Practice Address - Phone:337-504-3335
Practice Address - Fax:337-504-4795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-08
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA303881207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty