Provider Demographics
NPI:1710217492
Name:NETTERVILLE, JENNIFER E (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:E
Last Name:NETTERVILLE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:392 HALF MOON CT
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-5569
Mailing Address - Country:US
Mailing Address - Phone:318-347-5591
Mailing Address - Fax:318-222-0724
Practice Address - Street 1:700 E MARSHALL AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5580
Practice Address - Country:US
Practice Address - Phone:903-315-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-02
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA113324163W00000X
TX779616163W00000X
LAAP06036367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse