Provider Demographics
NPI:1033465778
Name:THREATTS, DANIELLE JACKSON
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:JACKSON
Last Name:THREATTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 N PARKERSON ST
Mailing Address - Street 2:
Mailing Address - City:RAYNE
Mailing Address - State:LA
Mailing Address - Zip Code:70578-6544
Mailing Address - Country:US
Mailing Address - Phone:337-534-4087
Mailing Address - Fax:
Practice Address - Street 1:105 INDEPENDENCE BLVD STE 1
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-8710
Practice Address - Country:US
Practice Address - Phone:337-534-4087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-31
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07019363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health