Healthcare Provider Details

I. General information

NPI: 1346761301
Provider Name (Legal Business Name): KORI FOGG JUBAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2017
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 ODONAVAN BLVD STE 404
WALKER LA
70785-6355
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 225-369-8100
  • Fax:
Mailing address:
  • Phone: 225-765-5727
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP09218
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: