Provider Demographics
NPI:1255507588
Name:JACKSON, WALTER CHARLES (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:CHARLES
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4051 VETERANS MEMORIAL BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-5567
Mailing Address - Country:US
Mailing Address - Phone:504-455-7161
Mailing Address - Fax:504-455-7162
Practice Address - Street 1:4051 VETERANS MEMORIAL BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-5572
Practice Address - Country:US
Practice Address - Phone:504-455-7161
Practice Address - Fax:504-455-7162
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-06
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA59271223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery