Basic Information
| Provider Information | |||||||||
| NPI: | 1306070198 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAGNE | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3525 PRYTANIA ST | ||||||||
| Address2: | SUITE 606 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701158109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048991513 | ||||||||
| FaxNumber: | 5048978637 | ||||||||
| Practice Location | |||||||||
| Address1: | 3525 PRYTANIA ST | ||||||||
| Address2: | SUITE 606 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701158109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048991513 | ||||||||
| FaxNumber: | 5048978637 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2009 | ||||||||
| LastUpdateDate: | 02/19/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | MD.205212 | LA | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 1925578 | 05 | LA | MEDICAID |