Healthcare Provider Details

I. General information

NPI: 1164817078
Provider Name (Legal Business Name): JESSICA SPEARS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 02/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6450 LOUISIANA HIGHWAY 1
INNIS LA
70747-4700
US

IV. Provider business mailing address

6450 LOUISIANA HIGHWAY 1
BATCHELOR LA
70715-3212
US

V. Phone/Fax

Practice location:
  • Phone: 225-492-3775
  • Fax: 225-492-3782
Mailing address:
  • Phone: 225-492-3775
  • Fax: 225-492-3782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN118313
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP08282
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: