Provider Demographics
NPI:1902450851
Name:GUILLORY, JED MICHAEL (FNP-C)
Entity Type:Individual
Prefix:
First Name:JED
Middle Name:MICHAEL
Last Name:GUILLORY
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4788 W NICK CLAIRE LN
Mailing Address - Street 2:
Mailing Address - City:IOWA
Mailing Address - State:LA
Mailing Address - Zip Code:70647-5148
Mailing Address - Country:US
Mailing Address - Phone:337-488-6843
Mailing Address - Fax:
Practice Address - Street 1:1701 OAK PARK BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8911
Practice Address - Country:US
Practice Address - Phone:337-494-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA207008363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily