Provider Demographics
NPI:1750302428
Name:JACKSON, THOMAS ISAAC (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ISAAC
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 HAWTHORNE DR
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-6066
Mailing Address - Country:US
Mailing Address - Phone:985-223-1986
Mailing Address - Fax:
Practice Address - Street 1:8166 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-3404
Practice Address - Country:US
Practice Address - Phone:985-873-4150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL024260207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine