Provider Demographics
NPI:1821167263
Name:JACKSON, BYRON ANDRA (MD)
Entity Type:Individual
Prefix:DR
First Name:BYRON
Middle Name:ANDRA
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:PO BOX 4587
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71134-0587
Mailing Address - Country:US
Mailing Address - Phone:318-221-0206
Mailing Address - Fax:
Practice Address - Street 1:745 OLIVE ST
Practice Address - Street 2:SUITE 203
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2246
Practice Address - Country:US
Practice Address - Phone:318-221-2054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08028R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAE07772Medicare UPIN
LA5J8888Medicare ID - Type Unspecified