Provider Demographics
NPI:1386402469
Name:JERRY, ANGIE (L-307666)
Entity type:Individual
Prefix:
First Name:ANGIE
Middle Name:
Last Name:JERRY
Suffix:
Gender:F
Credentials:L-307666
Other - Prefix:
Other - First Name:ANGIE
Other - Middle Name:
Other - Last Name:STEVENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:346 BROWN RD
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:LA
Mailing Address - Zip Code:71268-4717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:346 BROWN RD
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:LA
Practice Address - Zip Code:71268-4717
Practice Address - Country:US
Practice Address - Phone:318-614-8331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL-307666174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN