Provider Demographics
NPI:1659728772
Name:THORNTON, JENNIFER R (NP-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:THORNTON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 415000
Mailing Address - Street 2:LBX 410604
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37241-0604
Mailing Address - Country:US
Mailing Address - Phone:318-798-4664
Mailing Address - Fax:318-798-4457
Practice Address - Street 1:211 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-6052
Practice Address - Country:US
Practice Address - Phone:318-238-3322
Practice Address - Fax:318-238-3323
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08825363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2422456Medicaid
LA2422456Medicaid