Provider Demographics
NPI:1871630004
Name:JACKSON, LOUELLA M (FNPC)
Entity Type:Individual
Prefix:
First Name:LOUELLA
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 OPELOUSAS ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-2641
Mailing Address - Country:US
Mailing Address - Phone:337-439-9983
Mailing Address - Fax:337-439-8898
Practice Address - Street 1:2000 OPELOUSAS ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601
Practice Address - Country:US
Practice Address - Phone:337-439-9983
Practice Address - Fax:337-439-8898
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP03007363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1691810Medicaid
LAS50893Medicare UPIN
LA5X455Medicare ID - Type Unspecified