Healthcare Provider Details

I. General information

NPI: 1952521296
Provider Name (Legal Business Name): JENNIFER E AUTHEMENT RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 S RYAN ST
LAKE CHARLES LA
70601-5725
US

IV. Provider business mailing address

3850 BROOKEFLOWER CIRCLE N
LAKE CHARLES LA
70605
US

V. Phone/Fax

Practice location:
  • Phone: 337-431-7825
  • Fax:
Mailing address:
  • Phone: 337-474-7244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number1924
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: