Provider Demographics
NPI:1326146036
Name:JACKSON, PATRICIA A (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6019 CONSTANCE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70118-5806
Mailing Address - Country:US
Mailing Address - Phone:504-349-2908
Mailing Address - Fax:504-378-0019
Practice Address - Street 1:1111 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE N408
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072
Practice Address - Country:US
Practice Address - Phone:504-349-2908
Practice Address - Fax:504-378-0019
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA21655207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1660361Medicaid
LAG04325Medicare UPIN
LA5W143Medicare ID - Type Unspecified