Healthcare Provider Details

I. General information

NPI: 1154247039
Provider Name (Legal Business Name): JENNIFER MARIE DIMM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36545 ALBIN RD
INDEPENDENCE LA
70443-3910
US

IV. Provider business mailing address

36545 ALBIN RD
INDEPENDENCE LA
70443-3910
US

V. Phone/Fax

Practice location:
  • Phone: 504-322-0361
  • Fax:
Mailing address:
  • Phone: 504-322-0361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number006832838
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: