Provider Demographics
NPI:1255532842
Name:WOERNER, JENNIFER (DMD, MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WOERNER
Suffix:
Gender:F
Credentials:DMD, MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:WOERNER
Other - Last Name:HOUK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1501 KINGS HWY
Mailing Address - Street 2:ATTN: LEISA OGLESBY (RM. 1-201)
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-675-4881
Mailing Address - Fax:318-675-5069
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:DEPARTMENT OF ORAL SURGERY
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-4881
Practice Address - Fax:318-675-5069
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAS-483204E00000X
LA205899204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1507458Medicaid
LA292492YH54OtherMEDICARE - PTAN