Provider Demographics
NPI:1205074374
Name:BURTCH, JENNIFER ANN (ANP-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:BURTCH
Suffix:
Gender:F
Credentials:ANP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 AUTUMN WIND LN
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-7602
Mailing Address - Country:US
Mailing Address - Phone:985-960-6222
Mailing Address - Fax:
Practice Address - Street 1:2629 N CAUSEWAY BLVD
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-6049
Practice Address - Country:US
Practice Address - Phone:504-835-0565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-28
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN 106869 AP05448363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04789221Medicaid
LA0110142Medicaid
LA249413YH3UMedicare PIN