Healthcare Provider Details

I. General information

NPI: 1518065978
Provider Name (Legal Business Name): WALLACE JEANFREAU JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 01/31/2020
Certification Date: 01/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3530 HOUMA BLVD
METAIRIE LA
70006-4202
US

IV. Provider business mailing address

3800 HOUMA BLVD SUITE 335
METAIRIE LA
70006-4182
US

V. Phone/Fax

Practice location:
  • Phone: 504-264-5142
  • Fax:
Mailing address:
  • Phone: 504-779-5859
  • Fax: 985-626-6995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number015285
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: