Healthcare Provider Details

I. General information

NPI: 1295534667
Provider Name (Legal Business Name): JESSICA PRUETT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2025
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2539 VIKING DR STE 101
BOSSIER CITY LA
71111-2165
US

IV. Provider business mailing address

2539 VIKING DR STE 101
BOSSIER CITY LA
71111-2165
US

V. Phone/Fax

Practice location:
  • Phone: 318-747-8100
  • Fax: 318-747-8150
Mailing address:
  • Phone: 318-747-8100
  • Fax: 318-747-8150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number239904
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: