Basic Information
| Provider Information | |||||||||
| NPI: | 1376940130 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOOTHE | ||||||||
| FirstName: | JOEL | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN, BSN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1190 N STATE ST | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7692338239 | ||||||||
| FaxNumber: | 7692337865 | ||||||||
| Practice Location | |||||||||
| Address1: | 1190 N STATE ST | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7692338239 | ||||||||
| FaxNumber: | 7692337865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2014 | ||||||||
| LastUpdateDate: | 11/21/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R878782 | MS | Y | Nursing Service Providers | Registered Nurse |
No ID Information.