Provider Demographics
NPI:1215126891
Name:OBERLE, JEFFERSON KENNETH (PA-C)
Entity type:Individual
Prefix:MR
First Name:JEFFERSON
Middle Name:KENNETH
Last Name:OBERLE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5010 MANCUSO LN
Mailing Address - Street 2:APT # 921
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3594
Mailing Address - Country:US
Mailing Address - Phone:225-773-3669
Mailing Address - Fax:
Practice Address - Street 1:5000 HENNESSY BLVD
Practice Address - Street 2:OLOL ER
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4375
Practice Address - Country:US
Practice Address - Phone:225-765-8070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-18
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200070RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1036234Medicaid
LA1036234Medicaid