Healthcare Provider Details

I. General information

NPI: 1124499678
Provider Name (Legal Business Name): MALLORY JENKINS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2015
Last Update Date: 10/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15790 PAUL VEGA MD DR
HAMMOND LA
70403-1434
US

IV. Provider business mailing address

15790 PAUL VEGA MD DR
HAMMOND LA
70403-1434
US

V. Phone/Fax

Practice location:
  • Phone: 985-230-1682
  • Fax: 985-230-1617
Mailing address:
  • Phone: 985-230-1682
  • Fax: 985-230-1617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP08421
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: