Provider Demographics
NPI:1609554146
Name:GIBSON, JENNA RAE (FNP)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:RAE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 SHADOW OAK LN
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-1249
Mailing Address - Country:US
Mailing Address - Phone:504-800-8313
Mailing Address - Fax:
Practice Address - Street 1:807 SHADOW OAK LN
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-1249
Practice Address - Country:US
Practice Address - Phone:504-800-8313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA230156363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner