Healthcare Provider Details

I. General information

NPI: 1437711876
Provider Name (Legal Business Name): JENNIFER TUPPER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2019
Last Update Date: 09/12/2025
Certification Date: 09/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2508 BERT KOUNS INDUSTRIAL LOOP STE 101
SHREVEPORT LA
71118-3175
US

IV. Provider business mailing address

2508 BERT KOUNS INDUSTRIAL LOOP STE 101
SHREVEPORT LA
71118-3175
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-5811
  • Fax: 318-212-5844
Mailing address:
  • Phone: 318-212-5811
  • Fax: 318-212-5844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number227608
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number124754
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number1140664
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: