Provider Demographics
NPI:1851768642
Name:BROWN, JENNIFER M (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:BROWN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MORGAN
Other - Last Name:MADOLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3217 MABEL ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4022
Mailing Address - Country:US
Mailing Address - Phone:318-631-9121
Mailing Address - Fax:318-631-9126
Practice Address - Street 1:8383 MILLICENT WAY STE B
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115
Practice Address - Country:US
Practice Address - Phone:318-631-9121
Practice Address - Fax:318-213-6246
Is Sole Proprietor?:No
Enumeration Date:2015-08-27
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200876363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2402188Medicaid
LAPA.200876OtherLICENSE
LA447033YKACMedicare PIN