Provider Demographics
NPI:1861025868
Name:NICOLE JACKSON, DDS, A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:NICOLE JACKSON, DDS, A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:985-893-4882
Mailing Address - Street 1:5207 PINNACLE PKWY
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-9191
Mailing Address - Country:US
Mailing Address - Phone:985-893-4882
Mailing Address - Fax:985-893-4884
Practice Address - Street 1:5207 PINNACLE PKWY
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-9191
Practice Address - Country:US
Practice Address - Phone:985-893-4882
Practice Address - Fax:985-893-4884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty