Provider Demographics
NPI:1134092463
Name:MOUTON, JAKARA
Entity type:Individual
Prefix:MRS
First Name:JAKARA
Middle Name:
Last Name:MOUTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5224 75TH ST STE D
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-2525
Mailing Address - Country:US
Mailing Address - Phone:806-712-1096
Mailing Address - Fax:
Practice Address - Street 1:2810 AMBASSADOR CAFFERY PKWY FL 6
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-5906
Practice Address - Country:US
Practice Address - Phone:337-289-8180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-24
Last Update Date:2025-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA243073363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology