Healthcare Provider Details

I. General information

NPI: 1689231771
Provider Name (Legal Business Name): JAQUETTA CELESTINE LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2019
Last Update Date: 05/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 W ROWSON ST
WELSH LA
70591-3551
US

IV. Provider business mailing address

2110 OAK PARK BLVD
LAKE CHARLES LA
70601-7864
US

V. Phone/Fax

Practice location:
  • Phone: 337-802-2558
  • Fax:
Mailing address:
  • Phone: 337-475-0324
  • Fax: 337-475-8917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number20130906
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: