Healthcare Provider Details

I. General information

NPI: 1780889352
Provider Name (Legal Business Name): JESSICA TAYLOR NASH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 05/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 E BERT KOUNS SUITE 100
SHREVEPORT LA
71115
US

IV. Provider business mailing address

1811 E BERT KOUNS SUITE 100
SHREVEPORT LA
71115
US

V. Phone/Fax

Practice location:
  • Phone: 318-222-3695
  • Fax: 318-424-0717
Mailing address:
  • Phone: 318-222-3695
  • Fax: 318-424-0717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA.200115
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: