Healthcare Provider Details

I. General information

NPI: 1487253100
Provider Name (Legal Business Name): AMY JACOBS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2020
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1014 N PINE ST STE A
DERIDDER LA
70634-2818
US

IV. Provider business mailing address

1000 CHINABERRY DR STE 900
BOSSIER CITY LA
71111-2455
US

V. Phone/Fax

Practice location:
  • Phone: 337-463-4020
  • Fax: 337-463-4033
Mailing address:
  • Phone: 337-463-4020
  • Fax: 337-463-4033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberPLC11199
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: