Healthcare Provider Details

I. General information

NPI: 1649594441
Provider Name (Legal Business Name): JENNIFER D RODRIGUE PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2010
Last Update Date: 02/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 N ACADIA RD STE 200
THIBODAUX LA
70301-4897
US

IV. Provider business mailing address

604 N ACADIA RD STE 200
THIBODAUX LA
70301-4897
US

V. Phone/Fax

Practice location:
  • Phone: 985-448-3700
  • Fax: 985-448-3900
Mailing address:
  • Phone: 985-448-3700
  • Fax: 985-448-3900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN103839-AP06067
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: