Basic Information
| Provider Information | |||||||||
| NPI: | 1356946628 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUTLER | ||||||||
| FirstName: | JADA | ||||||||
| MiddleName: | DONIELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1712 WILLIAMSBURG DR | ||||||||
| Address2: | |||||||||
| City: | LA PLACE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700682819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9853590545 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1250 SW RAILROAD AVE STE 130 | ||||||||
| Address2: | |||||||||
| City: | HAMMOND | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704035013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9855003240 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2020 | ||||||||
| LastUpdateDate: | 12/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | 011486058 | LA | Y |
No ID Information.