Provider Demographics
NPI:1811044845
Name:JACKSON, MARCUS (DDS)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8847 VETERANS MEMORIAL BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70003-7707
Mailing Address - Country:US
Mailing Address - Phone:504-466-2392
Mailing Address - Fax:
Practice Address - Street 1:8847 VETERANS MEMORIAL BLVD STE B
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70003-7707
Practice Address - Country:US
Practice Address - Phone:504-466-2392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2489-89122300000X
LA56191223G0001X
MS2489-891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist