Provider Demographics
NPI:1962116905
Name:JACKSON, BARTHOLOMEW ERIC SR (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:BARTHOLOMEW
Middle Name:ERIC
Last Name:JACKSON
Suffix:SR
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7861 CAMELLIA BUD CT
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-6648
Mailing Address - Country:US
Mailing Address - Phone:315-281-6945
Mailing Address - Fax:
Practice Address - Street 1:7861 CAMELLIA BUD CT
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-6648
Practice Address - Country:US
Practice Address - Phone:315-281-6945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2203782084P0800X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA220378OtherPSYCHIATRY