Provider Demographics
NPI:1427587609
Name:NETTLES, JACQUELYN DEDRAL
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:DEDRAL
Last Name:NETTLES
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 1:315 S COLLEGE RD STE 252
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-3212
Mailing Address - Country:US
Mailing Address - Phone:337-269-1169
Mailing Address - Fax:337-235-1961
Practice Address - Street 1:315 S COLLEGE RD STE 252
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-3212
Practice Address - Country:US
Practice Address - Phone:337-269-1169
Practice Address - Fax:337-235-1961
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider