Provider Demographics
NPI:1518065978
Name:JEANFREAU, WALLACE JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:
Last Name:JEANFREAU
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 HOUMA BLVD
Mailing Address - Street 2:SUITE 335
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-4182
Mailing Address - Country:US
Mailing Address - Phone:504-779-5859
Mailing Address - Fax:985-626-6995
Practice Address - Street 1:3530 HOUMA BLVD
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-4202
Practice Address - Country:US
Practice Address - Phone:504-264-5142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015285207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1329088Medicaid
LA1329088Medicaid