Provider Demographics
NPI:1508510413
Name:CHAMPAGNE, JACOB ANTHONY (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:ANTHONY
Last Name:CHAMPAGNE
Suffix:
Gender:M
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 1:133 MADDOX JUDE DR
Mailing Address - Street 2:
Mailing Address - City:MAURICE
Mailing Address - State:LA
Mailing Address - Zip Code:70555-3355
Mailing Address - Country:US
Mailing Address - Phone:337-230-0104
Mailing Address - Fax:
Practice Address - Street 1:4801 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6917
Practice Address - Country:US
Practice Address - Phone:337-470-2911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA224252363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty