Healthcare Provider Details

I. General information

NPI: 1336994128
Provider Name (Legal Business Name): JENNIFER L STEWART NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2024
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1453 E BERT KOUNS INDUSTRIAL LOOP STE 112
SHREVEPORT LA
71105-6810
US

IV. Provider business mailing address

PO BOX 51008
SHREVEPORT LA
71135-1008
US

V. Phone/Fax

Practice location:
  • Phone: 318-798-9400
  • Fax: 318-795-4003
Mailing address:
  • Phone: 318-795-4618
  • Fax: 318-795-4003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number236032
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: