Provider Demographics
NPI:1922538057
Name:BUTZ, REBECCA (MS, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:
Last Name:BUTZ
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 WEST WOODROW WILSON AVENUE
Mailing Address - Street 2:2ND FLOOR, RENAL CLINIC
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213
Mailing Address - Country:US
Mailing Address - Phone:601-815-6572
Mailing Address - Fax:601-984-4151
Practice Address - Street 1:350 WEST WOODROW WILSON AVENUE
Practice Address - Street 2:2ND FLOOR, RENAL CLINIC
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213
Practice Address - Country:US
Practice Address - Phone:601-815-6572
Practice Address - Fax:601-984-4151
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD1624133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered