Provider Demographics
NPI:1679310072
Name:JOHNATHAN LARROQUETTE LLC
Entity type:Organization
Organization Name:JOHNATHAN LARROQUETTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JOHNATHAN
Authorized Official - Middle Name:THERON
Authorized Official - Last Name:LARROQUETTE
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:985-247-1394
Mailing Address - Street 1:PO BOX 51906
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-1906
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1214 COOLIDGE BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2621
Practice Address - Country:US
Practice Address - Phone:337-289-7991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-11
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1073060125Medicaid