Healthcare Provider Details

I. General information

NPI: 1538806179
Provider Name (Legal Business Name): MS. CHARLENE JACOBS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2022
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 WILLIAMS BLVD
KENNER LA
70062-7630
US

IV. Provider business mailing address

1017 KINLER ST
LULING LA
70070-4533
US

V. Phone/Fax

Practice location:
  • Phone: 504-416-1840
  • Fax:
Mailing address:
  • Phone: 504-416-1840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number441590119
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: