Healthcare Provider Details

I. General information

NPI: 1699703868
Provider Name (Legal Business Name): JENNIFER BOURGEIOS MARTIN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 09/06/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3510 N CAUSEWAY BLVD STE 404
METAIRIE LA
70002-3531
US

IV. Provider business mailing address

744 W MICHIGAN AVE
JACKSON MI
49201-1909
US

V. Phone/Fax

Practice location:
  • Phone: 504-779-5568
  • Fax:
Mailing address:
  • Phone: 517-787-6440
  • Fax: 517-787-4146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN097363
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP04719
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: