Healthcare Provider Details

I. General information

NPI: 1376190074
Provider Name (Legal Business Name): JENNIFER LAUREN MIRMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2019
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 CLEARVIEW PKWY
METAIRIE LA
70001-2437
US

IV. Provider business mailing address

2006 JENA ST
NEW ORLEANS LA
70115-5506
US

V. Phone/Fax

Practice location:
  • Phone: 504-535-4179
  • Fax:
Mailing address:
  • Phone: 973-985-9693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number14824
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number7018
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number7018
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: