Provider Demographics
NPI:1164510202
Name:JACKSON, ERIC WINFRED (RPT)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:WINFRED
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3662 INWOOD AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70131
Mailing Address - Country:US
Mailing Address - Phone:504-813-5065
Mailing Address - Fax:504-282-4407
Practice Address - Street 1:3662 INWOOD AVENUE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70131
Practice Address - Country:US
Practice Address - Phone:504-813-5065
Practice Address - Fax:504-282-4407
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06827R225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist