Provider Demographics
NPI:1659743029
Name:KENNETH JACKSON
Entity Type:Organization
Organization Name:KENNETH JACKSON
Other - Org Name:PIC ME UP TAXI AND TRANSPORTATION SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-419-8326
Mailing Address - Street 1:1216 OKLAHOMA ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70607-3624
Mailing Address - Country:US
Mailing Address - Phone:337-419-8236
Mailing Address - Fax:
Practice Address - Street 1:1216 OKLAHOMA ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-3624
Practice Address - Country:US
Practice Address - Phone:337-419-8236
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA008046248344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi