Provider Demographics
NPI:1003555624
Name:LABATUT, JACOB DWAYNE
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:DWAYNE
Last Name:LABATUT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 749495
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9495
Mailing Address - Country:US
Mailing Address - Phone:239-432-8331
Mailing Address - Fax:813-321-1296
Practice Address - Street 1:8585 PICARDY AVE STE 110
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3749
Practice Address - Country:US
Practice Address - Phone:225-767-0822
Practice Address - Fax:225-769-5424
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN154204163W00000X
LA226191363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse