Basic Information
| Provider Information | |||||||||
| NPI: | 1861718926 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THIBODAUX | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | BENOIT | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4176 | ||||||||
| Address2: | |||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703614176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858760300 | ||||||||
| FaxNumber: | 9858720317 | ||||||||
| Practice Location | |||||||||
| Address1: | 1320 MARTIN LUTHER KING DR | ||||||||
| Address2: | |||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703014886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854462021 | ||||||||
| FaxNumber: | 9854471546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2010 | ||||||||
| LastUpdateDate: | 12/07/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP06094 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 2169840 | 05 | LA | MEDICAID |