Provider Demographics
NPI:1124021092
Name:JACKSON PARISH AMBULANCE SERVICE DISTRICT
Entity type:Organization
Organization Name:JACKSON PARISH AMBULANCE SERVICE DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMS DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:BRANDON
Authorized Official - Last Name:WOLD
Authorized Official - Suffix:
Authorized Official - Credentials:BS EMT-P
Authorized Official - Phone:318-259-2877
Mailing Address - Street 1:115 WATTS ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71251-2053
Mailing Address - Country:US
Mailing Address - Phone:318-259-2891
Mailing Address - Fax:318-259-2099
Practice Address - Street 1:115 WATTS ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:LA
Practice Address - Zip Code:71251-2053
Practice Address - Country:US
Practice Address - Phone:318-259-2891
Practice Address - Fax:318-259-2099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA91100213416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAF4632OtherBLUE CROSS BLUE SHIELD
LA1550426Medicaid
LAP00634556OtherRAILROAD MEDICARE (PALMETTO GBA)
LA1550426Medicaid