Provider Demographics
NPI:1437801487
Name:STATUM, JARROD WAYNE (RSW)
Entity Type:Individual
Prefix:MR
First Name:JARROD
Middle Name:WAYNE
Last Name:STATUM
Suffix:
Gender:M
Credentials:RSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 KIRKMAN ST STE C
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5391
Mailing Address - Country:US
Mailing Address - Phone:337-990-5305
Mailing Address - Fax:
Practice Address - Street 1:1202 KIRKMAN ST STE C
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5391
Practice Address - Country:US
Practice Address - Phone:337-990-5305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-20
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA17045171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator