Provider Demographics
NPI:1447799390
Name:JACKSON, SHARON
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:
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 1:1220 BARATARIA BLVD
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3769
Mailing Address - Country:US
Mailing Address - Phone:504-340-6711
Mailing Address - Fax:504-348-3935
Practice Address - Street 1:1220 BARATARIA BLVD
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3769
Practice Address - Country:US
Practice Address - Phone:504-340-6711
Practice Address - Fax:504-348-3935
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP09011363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily