Provider Demographics
NPI:1295373025
Name:CROUCH, JACQUELINE CASEY
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:CASEY
Last Name:CROUCH
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 1:9051 EASTLAKE AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-0404
Mailing Address - Country:US
Mailing Address - Phone:225-610-8875
Mailing Address - Fax:
Practice Address - Street 1:NORTH STADIUM DRIVE ATHLETICS ADMINISTRATION BUILDING
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70803-0001
Practice Address - Country:US
Practice Address - Phone:225-578-2050
Practice Address - Fax:392-422-5578
Is Sole Proprietor?:No
Enumeration Date:2019-12-11
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program