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General NPI Number Information
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NPI Number | 1861921157
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Entity Type | Individual
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Provider Name | JELESSA PENN
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Gender | Female
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Dates
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Enumeration Date | 06/08/2017
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Last Update Date | 06/08/2017
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Provider Practice Location Address
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Address Line | 43 LUCILLE ST.
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City | WAGGAMAN
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State | LA
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Zip | 70094
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Country | US
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Telephone | 504-376-5944
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Fax |
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Provider Business Mailing Address
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Address Line | 43 LUCILLE ST
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City | WESTWEGO
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State | LA
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Zip | 70094-5818
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2000023890
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License Number State | LA
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