Provider Demographics
NPI:1851339477
Name:JO, JEANNIE Y (DPM)
Entity Type:Individual
Prefix:
First Name:JEANNIE
Middle Name:Y
Last Name:JO
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-765-5727
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:1014 SAINT CLAIR BLVD STE 3015
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-5030
Practice Address - Country:US
Practice Address - Phone:225-745-5500
Practice Address - Fax:225-743-2459
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LADPMPD326R213E00000X
CAE4654213E00000X
LAPD326R213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1714992Medicaid
MS06774745Medicaid
TX612103Medicare ID - Type Unspecified
LA1714992Medicaid
LA4K130Medicare PIN
LA4K1307061Medicare PIN