Basic Information
| Provider Information | |||||||||
| NPI: | 1164846838 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TYSON | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | NNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5959 S SHERWOOD FOREST BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708166038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257655727 | ||||||||
| FaxNumber: | 2257659196 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 713018124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3087693000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2014 | ||||||||
| LastUpdateDate: | 12/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LN0005X | AP07691 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal, Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 044440 | 01 | LA | STATE NARCOTICS LICENSE | OTHER | MT3166902 | 01 | LA | DEA | OTHER | AP07691 | 01 | LA | STATE LICENSE | OTHER | 2433725 | 05 | LA | MEDICAID |