Healthcare Provider Details

I. General information

NPI: 1023778503
Provider Name (Legal Business Name): JESSICA ELLEN CREDLE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2021
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2106 LOOP RD STE B
WINNSBORO LA
71295-3343
US

IV. Provider business mailing address

PO BOX 4506
SHREVEPORT LA
71134-0506
US

V. Phone/Fax

Practice location:
  • Phone: 318-239-4860
  • Fax: 805-295-4715
Mailing address:
  • Phone: 318-239-4860
  • Fax: 805-295-4715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number224185
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: