Provider Demographics
NPI:1477728947
Name:KHANNA, JESSICA (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:KHANNA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 W GREENS DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-8947
Mailing Address - Country:US
Mailing Address - Phone:817-683-2599
Mailing Address - Fax:
Practice Address - Street 1:1702 NORTH BURNSIDE AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70769
Practice Address - Country:US
Practice Address - Phone:225-647-4988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-25
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.204885207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine