Provider Demographics
NPI:1023778503
Name:CREDLE, JESSICA ELLEN (NP)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ELLEN
Last Name:CREDLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4506
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71134-0506
Mailing Address - Country:US
Mailing Address - Phone:318-239-4860
Mailing Address - Fax:805-295-4715
Practice Address - Street 1:2106 LOOP RD STE B
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295-3343
Practice Address - Country:US
Practice Address - Phone:318-239-4860
Practice Address - Fax:805-295-4715
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-23
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA224185363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner