Provider Demographics
NPI:1336701671
Name:JACKSON, RABUN DAKOTA
Entity Type:Individual
Prefix:
First Name:RABUN
Middle Name:DAKOTA
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 1:2236 HOYT DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-3384
Mailing Address - Country:US
Mailing Address - Phone:225-620-6773
Mailing Address - Fax:
Practice Address - Street 1:2236 HOYT DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-3384
Practice Address - Country:US
Practice Address - Phone:225-620-6773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment