Provider Demographics
NPI:1063055739
Name:SEPULVADO, JESSICA L (NP-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:SEPULVADO
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:589 TWIN SPRINGS LOOP
Mailing Address - Street 2:
Mailing Address - City:ZWOLLE
Mailing Address - State:LA
Mailing Address - Zip Code:71486-3681
Mailing Address - Country:US
Mailing Address - Phone:318-521-0820
Mailing Address - Fax:
Practice Address - Street 1:210 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:MANY
Practice Address - State:LA
Practice Address - Zip Code:71449-3718
Practice Address - Country:US
Practice Address - Phone:318-256-5722
Practice Address - Fax:318-256-5774
Is Sole Proprietor?:No
Enumeration Date:2019-10-24
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAF10190070363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAF10190070OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICATION BOARD