Healthcare Provider Details

I. General information

NPI: 1669094397
Provider Name (Legal Business Name): JACOB HUNTER PHILLIPS AGACNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2020
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 JUDGE TANNER BLVD
COVINGTON LA
70433-7500
US

IV. Provider business mailing address

PO BOX 3370
COVINGTON LA
70434-3370
US

V. Phone/Fax

Practice location:
  • Phone: 985-867-3800
  • Fax: 985-867-3644
Mailing address:
  • Phone: 985-867-8585
  • Fax: 985-867-3644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number903925
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number212776
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: