Provider Demographics
NPI:1629186812
Name:WHITE, JACQUELYN KIBODEAUX (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:KIBODEAUX
Last Name:WHITE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 RIDGEMONT ST
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-9596
Mailing Address - Country:US
Mailing Address - Phone:318-251-8838
Mailing Address - Fax:
Practice Address - Street 1:4001 RIDGEMONT ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-9596
Practice Address - Country:US
Practice Address - Phone:318-251-8838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA201607207Q00000X
LA021607207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1121991Medicaid
LA1121991Medicaid
LA4K536DF59Medicare PIN