Provider Demographics
NPI:1437711876
Name:TUPPER, JENNIFER (APRN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:TUPPER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8315 N PARK LN
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-9121
Mailing Address - Country:US
Mailing Address - Phone:318-617-6566
Mailing Address - Fax:
Practice Address - Street 1:625 RUSSELL BLVD
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1247
Practice Address - Country:US
Practice Address - Phone:936-305-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-06
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA124754163WP0200X
TX1140664363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics