Provider Demographics
NPI:1427273713
Name:JACKSON, PATRICK LOUIS SR
Entity type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:LOUIS
Last Name:JACKSON
Suffix:SR
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 1:58110 W W HARLEAUX ST
Mailing Address - Street 2:P.O . BOX -986
Mailing Address - City:PLAQUEMINE
Mailing Address - State:LA
Mailing Address - Zip Code:70764-3230
Mailing Address - Country:US
Mailing Address - Phone:225-385-4251
Mailing Address - Fax:225-385-4251
Practice Address - Street 1:58110 W W HARLEAUX ST
Practice Address - Street 2:
Practice Address - City:PLAQUEMINE
Practice Address - State:LA
Practice Address - Zip Code:70764-3230
Practice Address - Country:US
Practice Address - Phone:225-385-4251
Practice Address - Fax:225-385-4251
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA332B00000X332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies