Provider Demographics
NPI:1740781749
Name:BOUTTE, JESSICA LAUREN (RN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LAUREN
Last Name:BOUTTE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LAUREN
Other - Last Name:HACKWORTH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:34 PEBBLE BEACH ST
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79606-5039
Mailing Address - Country:US
Mailing Address - Phone:817-863-8017
Mailing Address - Fax:
Practice Address - Street 1:34 PEBBLE BEACH ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606-5039
Practice Address - Country:US
Practice Address - Phone:817-863-8017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-24
Last Update Date:2018-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX782988163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse