Provider Demographics
NPI:1679986673
Name:JACKSON, MARIAH (FNP-C)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 S PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-6802
Mailing Address - Country:US
Mailing Address - Phone:504-473-6459
Mailing Address - Fax:
Practice Address - Street 1:5646 READ BLVD
Practice Address - Street 2:STE280
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70127-3106
Practice Address - Country:US
Practice Address - Phone:504-246-1452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07812363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09034856Medicaid
LA2370472Medicaid
LA356813YH3UMedicare PIN