Provider Demographics
NPI:1629454160
Name:KING, JESSICA ANN (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:KING
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:KING
Other - Last Name:TIDWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2727 HEARNE AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3918
Mailing Address - Country:US
Mailing Address - Phone:318-631-6400
Mailing Address - Fax:318-631-0300
Practice Address - Street 1:2727 HEARNE AVE STE 301
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3918
Practice Address - Country:US
Practice Address - Phone:318-631-6400
Practice Address - Fax:318-631-0300
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP130723363LA2100X
LAAP08445363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-2616977-123OtherTRICARE
TX752616977180OtherTRICARE
TX352279902Medicaid
TXP01784015OtherRAIL ROAD MEDICARE
TXP01784015OtherRAIL ROAD MEDICARE