Provider Demographics
NPI:1144829540
Name:BLUNDELL, JENNA NICOLE (FNP)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:NICOLE
Last Name:BLUNDELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 RAGAN LN
Mailing Address - Street 2:
Mailing Address - City:HAUGHTON
Mailing Address - State:LA
Mailing Address - Zip Code:71037-8994
Mailing Address - Country:US
Mailing Address - Phone:641-990-3361
Mailing Address - Fax:
Practice Address - Street 1:1811 E BERT KOUNS INDUSTRIAL LOOP STE 210
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5740
Practice Address - Country:US
Practice Address - Phone:318-212-3858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-19
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA216026363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner