Healthcare Provider Details

I. General information

NPI: 1821501388
Provider Name (Legal Business Name): KEIELLA BUTLER PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2017
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 HIGHWAY 80 W
JACKSON MS
39209
US

IV. Provider business mailing address

3450 HIGHWAY 80 W
JACKSON MS
39209-7201
US

V. Phone/Fax

Practice location:
  • Phone: 601-321-2400
  • Fax:
Mailing address:
  • Phone: 601-321-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number902338
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: