Healthcare Provider Details

I. General information

NPI: 1447929864
Provider Name (Legal Business Name): JESSICA N STANFORD MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 MELANIE DR
SULPHUR LA
70663-5944
US

IV. Provider business mailing address

1118 MELANIE DR
SULPHUR LA
70663-5944
US

V. Phone/Fax

Practice location:
  • Phone: 337-540-8602
  • Fax:
Mailing address:
  • Phone: 337-540-8602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1744R1102X
TaxonomyResearch Study Specialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: