Provider Demographics
NPI:1639542087
Name:WHITE, JENNA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:MARIE
Last Name:WHITE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1902 ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-2508
Mailing Address - Country:US
Mailing Address - Phone:318-512-1787
Mailing Address - Fax:
Practice Address - Street 1:300 PAVILION RD
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71292-9470
Practice Address - Country:US
Practice Address - Phone:318-512-1787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-06
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA300081363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09478866Medicaid
LA2410199Medicaid
LA472603YH3VMedicare PIN