Provider Demographics
NPI:1073216719
Name:JACKSON, RACINE DOMINIQUE (NP)
Entity Type:Individual
Prefix:
First Name:RACINE
Middle Name:DOMINIQUE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:RACINE
Other - Middle Name:DOMINIQUE
Other - Last Name:CUNNINGHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2525 W ORICE ROTH RD APT 1510
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-5336
Mailing Address - Country:US
Mailing Address - Phone:225-348-3997
Mailing Address - Fax:
Practice Address - Street 1:2525 W ORICE ROTH RD APT 1510
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-5336
Practice Address - Country:US
Practice Address - Phone:225-348-3997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA229255363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily