Provider Demographics
NPI:1104233923
Name:DEDEAUX, JEREMY (FNP-C)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:DEDEAUX
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2335 MAIN STREET
Mailing Address - Street 2:SUITE E
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791
Mailing Address - Country:US
Mailing Address - Phone:225-654-3607
Mailing Address - Fax:225-658-2262
Practice Address - Street 1:2335 CHURCH ST
Practice Address - Street 2:SUITE E
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-2700
Practice Address - Country:US
Practice Address - Phone:225-654-3607
Practice Address - Fax:225-658-2262
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-14
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07961363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2381547Medicaid
373480YK2HMedicare PIN