Healthcare Provider Details

I. General information

NPI: 1962534776
Provider Name (Legal Business Name): JESSICA JEANNE LLAMAS LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18321 SHADOW CREEK AVE
BATON ROUGE LA
70816-3779
US

IV. Provider business mailing address

18321 SHADOW CREEK AVE
BATON ROUGE LA
70816-3779
US

V. Phone/Fax

Practice location:
  • Phone: 225-755-4079
  • Fax:
Mailing address:
  • Phone: 225-755-4079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberATH.J00140
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: