Provider Demographics
NPI:1033367529
Name:JACKSON-WILSON, ANDREA LATRESE (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:LATRESE
Last Name:JACKSON-WILSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 N FOSTER DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-1818
Mailing Address - Country:US
Mailing Address - Phone:225-987-9000
Mailing Address - Fax:
Practice Address - Street 1:5825 AIRLINE HWY
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70805-2408
Practice Address - Country:US
Practice Address - Phone:225-358-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-09
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP05569363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1311901Medicaid
LA1311901Medicaid