Provider Demographics
NPI:1902612740
Name:JACKSON, KENNETH MARLON
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:MARLON
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 1:8630 ANTIOCH RD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-6413
Mailing Address - Country:US
Mailing Address - Phone:504-667-8133
Mailing Address - Fax:
Practice Address - Street 1:8630 ANTIOCH RD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-6413
Practice Address - Country:US
Practice Address - Phone:504-667-8133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-06
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA002515859172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty