Provider Demographics
NPI:1407296775
Name:JACKSON, DARRIN (MD)
Entity Type:Individual
Prefix:
First Name:DARRIN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 CORPORATE SQUARE DR STE A
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-3151
Mailing Address - Country:US
Mailing Address - Phone:985-259-4854
Mailing Address - Fax:855-807-4750
Practice Address - Street 1:1415 CORPORATE SQUARE DR STE A
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-3151
Practice Address - Country:US
Practice Address - Phone:985-259-4854
Practice Address - Fax:855-807-4750
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-01
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-2680207Q00000X
LA302304207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05427361Medicaid
LA2427806Medicaid
LA525518YH3UMedicare PIN