Healthcare Provider Details

I. General information

NPI: 1104233923
Provider Name (Legal Business Name): JEREMY DEDEAUX FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2014
Last Update Date: 12/06/2022
Certification Date: 12/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2335 CHURCH ST SUITE E
ZACHARY LA
70791-2700
US

IV. Provider business mailing address

2335 MAIN STREET SUITE E
ZACHARY LA
70791
US

V. Phone/Fax

Practice location:
  • Phone: 225-654-3607
  • Fax: 225-658-2262
Mailing address:
  • Phone: 225-654-3607
  • Fax: 225-658-2262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP07961
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: