Healthcare Provider Details

I. General information

NPI: 1891831376
Provider Name (Legal Business Name): JEFFERSON COMMUNITY HEALTH CARE CENTERS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 10/10/2023
Certification Date: 10/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7001 LAPALCO BLVD
MARRERO LA
70072
US

IV. Provider business mailing address

PO BOX 2490
MARRERO LA
70073-2490
US

V. Phone/Fax

Practice location:
  • Phone: 504-371-8958
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateLA

VIII. Authorized Official

Name: SHELLY FOURCADE
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 985-781-8565