Healthcare Provider Details

I. General information

NPI: 1720902695
Provider Name (Legal Business Name): MS. JAMIE LENA ETIENNE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3549 GILMER RD STE T
LONGVIEW TX
75604-1257
US

IV. Provider business mailing address

3549 GILMER RD STE T
LONGVIEW TX
75604-1257
US

V. Phone/Fax

Practice location:
  • Phone: 903-315-2160
  • Fax:
Mailing address:
  • Phone: 903-315-2160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1072176
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: