Provider Demographics
NPI:1134357064
Name:JENNIFER R. MCCANN, M.D., LLC
Entity type:Organization
Organization Name:JENNIFER R. MCCANN, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-463-5582
Mailing Address - Street 1:206 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-4856
Mailing Address - Country:US
Mailing Address - Phone:337-463-5582
Mailing Address - Fax:337-460-1348
Practice Address - Street 1:206 W 5TH ST
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-4856
Practice Address - Country:US
Practice Address - Phone:337-463-5582
Practice Address - Fax:337-460-1348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA201272174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1093271Medicaid