Provider Demographics
NPI:1306546874
Name:JACKSON, GERARD (OWNER)
Entity type:Individual
Prefix:
First Name:GERARD
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3173 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70802-2178
Mailing Address - Country:US
Mailing Address - Phone:225-778-7678
Mailing Address - Fax:225-341-6825
Practice Address - Street 1:3173 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70802-2178
Practice Address - Country:US
Practice Address - Phone:225-614-8960
Practice Address - Fax:225-341-6825
Is Sole Proprietor?:No
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5399927Medicaid