Provider Demographics
NPI:1952444754
Name:KITTRELL, JIMMY L JR (MD)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:L
Last Name:KITTRELL
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 E I 10 SERVICE RD
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-3564
Mailing Address - Country:US
Mailing Address - Phone:985-280-9909
Mailing Address - Fax:985-646-2335
Practice Address - Street 1:140 E I 10 SERVICE RD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-3564
Practice Address - Country:US
Practice Address - Phone:985-280-9909
Practice Address - Fax:985-646-2335
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17573207R00000X
LAMD.024281207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014343Medicaid
MSH47073Medicare UPIN
MS09014343Medicaid