Provider Demographics
NPI:1588795405
Name:BANKS, JENNIFER W (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:W
Last Name:BANKS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:411 E VAUGHN AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-5972
Mailing Address - Country:US
Mailing Address - Phone:318-521-3774
Mailing Address - Fax:318-251-0442
Practice Address - Street 1:411 E VAUGHN AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5972
Practice Address - Country:US
Practice Address - Phone:318-251-3774
Practice Address - Fax:318-251-0442
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAAPO3690363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1436283Medicaid
LA1436283Medicaid
LA4B458Medicare ID - Type UnspecifiedPART B