Provider Demographics
NPI:1033379524
Name:JACKSON, STEVEN MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:MICHAEL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2475
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-2475
Mailing Address - Country:US
Mailing Address - Phone:318-663-6131
Mailing Address - Fax:318-214-4651
Practice Address - Street 1:601 KEYSER AVE
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-6020
Practice Address - Country:US
Practice Address - Phone:318-354-2555
Practice Address - Fax:318-354-0101
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LADO.322073208600000X
ALDO.1281208600000X
ARE6004208600000X
FLOS10093208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023297600Medicaid
AL000139622Medicaid
AR178509003Medicaid
AL102I027650Medicare PIN