Provider Demographics
NPI:1699851931
Name:JACKSON, PAMELA TAYLOR (DNP)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:TAYLOR
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:MRS
Other - First Name:PAMELA
Other - Middle Name:LAVERNE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:226 LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-3346
Mailing Address - Country:US
Mailing Address - Phone:337-678-1630
Mailing Address - Fax:337-678-1635
Practice Address - Street 1:226 LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-3346
Practice Address - Country:US
Practice Address - Phone:337-678-1630
Practice Address - Fax:337-678-1635
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-30
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP03530363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1563404Medicaid
LA4B540OtherMEDICARE PTAN
LA1563404Medicaid