Provider Demographics
NPI:1891795191
Name:MUKKASNNAIRU, JAYASANKARAN P (MD)
Entity Type:Individual
Prefix:DR
First Name:JAYASANKARAN
Middle Name:P
Last Name:MUKKASNNAIRU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MUKKASNNAIRU
Other - Middle Name:P
Other - Last Name:JAYASANKARAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:8415 GOODWOOD BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-7851
Mailing Address - Country:US
Mailing Address - Phone:225-765-5500
Mailing Address - Fax:225-765-5634
Practice Address - Street 1:8415 GOODWOOD BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-7851
Practice Address - Country:US
Practice Address - Phone:225-765-5633
Practice Address - Fax:225-765-5634
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12842R208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08636816Medicaid
LA1547646Medicaid
LA1547646Medicaid
LAH14480Medicare UPIN