Healthcare Provider Details

I. General information

NPI: 1467968156
Provider Name (Legal Business Name): WILLIAM CODY JENKINS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2017
Last Update Date: 08/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 GAUSE BLVD
SLIDELL LA
70458-2939
US

IV. Provider business mailing address

120 INNWOOD DR
COVINGTON LA
70433-9123
US

V. Phone/Fax

Practice location:
  • Phone: 985-649-8767
  • Fax: 985-649-8838
Mailing address:
  • Phone: 985-234-0542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95410
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9368756
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN6711331
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95410
License Number StateWV
# 5
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number203444
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: