Provider Demographics
NPI:1558041491
Name:JACKSON, REGINALD D
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 S COLLEGE RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-3352
Mailing Address - Country:US
Mailing Address - Phone:337-269-1165
Mailing Address - Fax:
Practice Address - Street 1:515 S COLLEGE RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-3352
Practice Address - Country:US
Practice Address - Phone:337-269-1165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider