Provider Demographics
NPI:1740687334
Name:BENNETT, JO LYNN (ACNPC-AG)
Entity type:Individual
Prefix:MRS
First Name:JO
Middle Name:LYNN
Last Name:BENNETT
Suffix:
Gender:F
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:JO
Other - Middle Name:LYNN
Other - Last Name:PEACOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:JO LYNN O'QUAIN
Mailing Address - Street 1:1401 LOUISA ST
Mailing Address - Street 2:
Mailing Address - City:RAYVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71269-3245
Mailing Address - Country:US
Mailing Address - Phone:318-334-5825
Mailing Address - Fax:318-301-6826
Practice Address - Street 1:1401 LOUISA ST
Practice Address - Street 2:
Practice Address - City:RAYVILLE
Practice Address - State:LA
Practice Address - Zip Code:71269-3245
Practice Address - Country:US
Practice Address - Phone:318-334-5825
Practice Address - Fax:318-301-6826
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08079363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2382942Medicaid