Provider Demographics
NPI:1568728103
Name:BUTLER, JACQUELINE FONTENOT (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:FONTENOT
Last Name:BUTLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:RENEE
Other - Last Name:FONTENOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2901 N FOURTH ST
Mailing Address - Street 2:EMERGENCY ROOM
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605
Mailing Address - Country:US
Mailing Address - Phone:903-758-1818
Mailing Address - Fax:
Practice Address - Street 1:2901 N FOURTH ST
Practice Address - Street 2:EMERGENCY ROOM
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605
Practice Address - Country:US
Practice Address - Phone:903-758-1818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-09
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ2519207P00000X
LA206671207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2188453Medicaid
LA2188453Medicaid