Provider Demographics
NPI:1508975111
Name:LANDRY, JESSICA LYNN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LYNN
Last Name:LANDRY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 SUMMERTYME DRIVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70592
Mailing Address - Country:US
Mailing Address - Phone:337-856-0973
Mailing Address - Fax:337-261-6585
Practice Address - Street 1:2390 W CONGRESS STREET
Practice Address - Street 2:UNIVERSITY MED CENTER
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70596
Practice Address - Country:US
Practice Address - Phone:337-261-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN100751363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1478890Medicaid
LA4H401Medicare ID - Type Unspecified