Provider Demographics
NPI:1942590153
Name:BOURGEOIS, JENNA MARTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNA
Middle Name:MARTIN
Last Name:BOURGEOIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:BILAN
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8777 BLUEBONNET BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-2975
Mailing Address - Country:US
Mailing Address - Phone:225-432-0000
Mailing Address - Fax:225-766-1995
Practice Address - Street 1:8777 BLUEBONNET BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-2975
Practice Address - Country:US
Practice Address - Phone:225-432-0000
Practice Address - Fax:225-766-1995
Is Sole Proprietor?:No
Enumeration Date:2011-04-10
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA3043322086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2441574Medicaid