Provider Demographics
NPI:1831311067
Name:LANDRY, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LANDRY
Suffix:
Gender:F
Credentials:
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 732
Mailing Address - Street 2:
Mailing Address - City:NEW ROADS
Mailing Address - State:LA
Mailing Address - Zip Code:70760-0732
Mailing Address - Country:US
Mailing Address - Phone:225-618-9955
Mailing Address - Fax:
Practice Address - Street 1:142 NEW ROADS ST
Practice Address - Street 2:
Practice Address - City:NEW ROADS
Practice Address - State:LA
Practice Address - Zip Code:70760-3508
Practice Address - Country:US
Practice Address - Phone:225-618-9955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.Z12004225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1473758Medicaid