Provider Demographics
NPI:1104149905
Name:JORY, GINA THERIOT (NP)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:THERIOT
Last Name:JORY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5247 DIDESSE DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-9153
Mailing Address - Country:US
Mailing Address - Phone:225-765-3076
Mailing Address - Fax:225-765-3090
Practice Address - Street 1:5247 DIDESSE DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-9153
Practice Address - Country:US
Practice Address - Phone:225-765-3076
Practice Address - Fax:225-765-3090
Is Sole Proprietor?:No
Enumeration Date:2010-03-08
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06049363L00000X
LARN 098182363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2113101Medicaid
LAP00858048OtherRAIL ROAD MEDICARE #
LA3B869D279Medicare PIN