Provider Demographics
NPI:1336284819
Name:JACKSON, DANNY J SR (PD)
Entity Type:Individual
Prefix:
First Name:DANNY
Middle Name:J
Last Name:JACKSON
Suffix:SR
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6437 TWIN BRIDGES RD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-7714
Mailing Address - Country:US
Mailing Address - Phone:318-445-5579
Mailing Address - Fax:318-767-5330
Practice Address - Street 1:5352 HOSPITAL BLVD
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360
Practice Address - Country:US
Practice Address - Phone:318-473-6257
Practice Address - Fax:318-767-5330
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14055183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA14055OtherPHARMACY LICENSE NUMBER