Healthcare Provider Details

I. General information

NPI: 1174407076
Provider Name (Legal Business Name): JEANNA ROBERTA JEAN LOUIS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2025
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 BLOOMFIELD AVE
BLOOMFIELD NJ
07003
US

IV. Provider business mailing address

220 BLOOMFIELD AVE
BLOOMFIELD NJ
07003
US

V. Phone/Fax

Practice location:
  • Phone: 973-520-2591
  • Fax:
Mailing address:
  • Phone: 973-520-2591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ15357800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: