Basic Information
| Provider Information | |||||||||
| NPI: | 1851339477 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JO | ||||||||
| FirstName: | JEANNIE | ||||||||
| MiddleName: | Y. | ||||||||
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| Credential: | D.P.M. | ||||||||
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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: | 1014 SAINT CLAIR BLVD STE 3015 | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707375030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257455500 | ||||||||
| FaxNumber: | 2257432459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 03/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | DPMPD326R | LA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | E4654 | CA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | PD326R | LA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 1714992 | 05 | LA | MEDICAID | 06774745 | 05 | MS | MEDICAID |