Provider Demographics
NPI:1063497683
Name:JACKSON, JOHN G (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13030 HIGHWAY 308
Mailing Address - Street 2:
Mailing Address - City:LAROSE
Mailing Address - State:LA
Mailing Address - Zip Code:70373-2001
Mailing Address - Country:US
Mailing Address - Phone:985-798-7000
Mailing Address - Fax:985-798-7021
Practice Address - Street 1:13030 HIGHWAY 308
Practice Address - Street 2:
Practice Address - City:LAROSE
Practice Address - State:LA
Practice Address - Zip Code:70373-2001
Practice Address - Country:US
Practice Address - Phone:985-798-7000
Practice Address - Fax:985-798-7021
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15556207Q00000X
LAMD019331207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1030589Medicaid
E33769Medicare UPIN
LA1030589Medicaid