Provider Demographics
NPI:1154058162
Name:JACKSON, KENNETH LEE
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:LEE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 OKLAHOMA ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70607-3624
Mailing Address - Country:US
Mailing Address - Phone:337-414-0914
Mailing Address - Fax:
Practice Address - Street 1:1216 OKLAHOMA ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-3624
Practice Address - Country:US
Practice Address - Phone:337-414-0914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)