Healthcare Provider Details

I. General information

NPI: 1760666556
Provider Name (Legal Business Name): JESSICA RENEE GAUTREAUX M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2007
Last Update Date: 06/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HENRY CLAY AVE
NEW ORLEANS LA
70118-5720
US

IV. Provider business mailing address

200 HENRY CLAY AVE
NEW ORLEANS LA
70118-5720
US

V. Phone/Fax

Practice location:
  • Phone: 504-894-6783
  • Fax: 504-894-4150
Mailing address:
  • Phone: 504-894-9458
  • Fax: 504-894-4150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberMD.202892
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: