Provider Demographics
NPI:1376940130
Name:BOOTHE, JOEL CHRISTOPHER (RN, BSN)
Entity Type:Individual
Prefix:MR
First Name:JOEL
Middle Name:CHRISTOPHER
Last Name:BOOTHE
Suffix:
Gender:M
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1190 N STATE ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2413
Mailing Address - Country:US
Mailing Address - Phone:769-233-8239
Mailing Address - Fax:769-233-7865
Practice Address - Street 1:1190 N STATE ST
Practice Address - Street 2:SUITE 301
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2413
Practice Address - Country:US
Practice Address - Phone:769-233-8239
Practice Address - Fax:769-233-7865
Is Sole Proprietor?:No
Enumeration Date:2014-11-21
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR878782163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse