Provider Demographics
NPI:1588373716
Name:JACKSON, KODI LONG (PA)
Entity type:Individual
Prefix:
First Name:KODI
Middle Name:LONG
Last Name:JACKSON
Suffix:
Gender:
Credentials:PA
Other - Prefix:MISS
Other - First Name:KODI
Other - Middle Name:DANIELE
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:601-200-4644
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:969 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4606
Practice Address - Country:US
Practice Address - Phone:601-200-2280
Practice Address - Fax:601-200-0229
Is Sole Proprietor?:No
Enumeration Date:2022-11-16
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant