Healthcare Provider Details

I. General information

NPI: 1053433102
Provider Name (Legal Business Name): JODIE MARIE ROTH LAFEUILLADE RN, MSN, CPNP-AC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 W 38TH ST STE 410
AUSTIN TX
78705-1162
US

IV. Provider business mailing address

901 W 38TH ST STE 410
AUSTIN TX
78705-1162
US

V. Phone/Fax

Practice location:
  • Phone: 512-992-1378
  • Fax: 512-992-1379
Mailing address:
  • Phone: 512-992-1378
  • Fax: 512-992-1379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number740243
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number740243
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number740243
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: