Provider Demographics
NPI:1497560320
Name:BUTLER-SUMPTER, JACOB ROY LAVERN I (DSP)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:ROY LAVERN
Last Name:BUTLER-SUMPTER
Suffix:I
Gender:M
Credentials:DSP
Other - Prefix:MR
Other - First Name:JACOB
Other - Middle Name:ROY LAVERN
Other - Last Name:SUMPTER
Other - Suffix:I
Other - Last Name Type:Other Name
Other - Credentials:DSP
Mailing Address - Street 1:2610 W M CT
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68522-1006
Mailing Address - Country:US
Mailing Address - Phone:402-325-8555
Mailing Address - Fax:
Practice Address - Street 1:2600 W M CT
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68522-1008
Practice Address - Country:US
Practice Address - Phone:402-325-8555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist