Healthcare Provider Details

I. General information

NPI: 1497100580
Provider Name (Legal Business Name): KORTNEY JACOBSEN NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KORTNEY MCMULLIN NURSE PRACTITIONER

II. Dates (important events)

Enumeration Date: 04/26/2016
Last Update Date: 01/21/2025
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 WESTGATE ROAD
SCOTT LA
70506
US

IV. Provider business mailing address

203 WESTGATE ROAD
SCOTT LA
70506
US

V. Phone/Fax

Practice location:
  • Phone: 337-326-4569
  • Fax:
Mailing address:
  • Phone: 435-749-1488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP212553
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6211903-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: