Healthcare Provider Details

I. General information

NPI: 1174084396
Provider Name (Legal Business Name): JESSICA EVANS MCKENZIE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2019
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 HOMER RD
MINDEN LA
71055-2933
US

IV. Provider business mailing address

815 S PINE ST
VIVIAN LA
71082-3314
US

V. Phone/Fax

Practice location:
  • Phone: 318-377-8855
  • Fax:
Mailing address:
  • Phone: 183-753-2353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number323683
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number323683
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: