Provider Demographics
NPI:1659503092
Name:PORTACCI, JAMIE MARIE (APRN, FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:MARIE
Last Name:PORTACCI
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:MS
Other - First Name:JAMIE
Other - Middle Name:MARIE
Other - Last Name:BRANCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1200 S FARMERVILLE ST
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-5941
Mailing Address - Country:US
Mailing Address - Phone:318-255-3690
Mailing Address - Fax:318-251-6116
Practice Address - Street 1:1809 NORTHPOINTE LN STE 102
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270
Practice Address - Country:US
Practice Address - Phone:318-255-3762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-19
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN065346363L00000X
LAAPO5948363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1820385Medicaid
LA347829YJ06Medicare PIN