Provider Demographics
NPI:1821507542
Name:JENNINGS PEDIATRIC CENTER, LLC
Entity Type:Organization
Organization Name:JENNINGS PEDIATRIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE NURSE
Authorized Official - Prefix:MRS
Authorized Official - First Name:MIKKI
Authorized Official - Middle Name:D
Authorized Official - Last Name:MONCEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-824-3446
Mailing Address - Street 1:1615 JOHNSON ST STE A
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70546-3650
Mailing Address - Country:US
Mailing Address - Phone:337-824-3446
Mailing Address - Fax:337-824-7990
Practice Address - Street 1:1615 JOHNSON ST STE A
Practice Address - Street 2:
Practice Address - City:JENNINGS
Practice Address - State:LA
Practice Address - Zip Code:70546-3650
Practice Address - Country:US
Practice Address - Phone:337-824-3446
Practice Address - Fax:337-824-7990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-26
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08542R261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1649651571Medicaid