Basic Information
| Provider Information | |||||||||
| NPI: | 1053813048 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUTER CALLOWAY | ||||||||
| FirstName: | JACQUELINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 SAXONY DR | ||||||||
| Address2: | |||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703642871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2282237968 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1418 TIGER DR | ||||||||
| Address2: | |||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703014337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854494055 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2018 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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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 | 171M00000X | 9903 | LA | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 780830 | 01 | LA | LOUISIANA STATE BOARD OF PRACTICAL NURSING | OTHER | 9903 | 01 | LA | LOUISIANA STATE BOARD OF SOCIAL WORK | OTHER |