Provider Demographics
NPI:1962639229
Name:BOUTTE, JEFFREY (LSA)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:BOUTTE
Suffix:
Gender:M
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3210 ROCK BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75227-5649
Mailing Address - Country:US
Mailing Address - Phone:214-364-6769
Mailing Address - Fax:
Practice Address - Street 1:3210 ROCK BLUFF DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75227-5649
Practice Address - Country:US
Practice Address - Phone:214-364-6769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-14
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00755246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant