Provider Demographics
NPI:1093416513
Name:JACKSON, JAMIE LUNEAU
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LUNEAU
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20264 NEAL RD
Mailing Address - Street 2:
Mailing Address - City:LORANGER
Mailing Address - State:LA
Mailing Address - Zip Code:70446-3006
Mailing Address - Country:US
Mailing Address - Phone:225-456-3665
Mailing Address - Fax:
Practice Address - Street 1:20264 NEAL RD
Practice Address - Street 2:
Practice Address - City:LORANGER
Practice Address - State:LA
Practice Address - Zip Code:70446-3006
Practice Address - Country:US
Practice Address - Phone:225-456-3665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-13
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA229279363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily