Provider Demographics
NPI:1982194635
Name:JACKSON, WANDA MARIE
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BELLE CHASSE
Mailing Address - State:LA
Mailing Address - Zip Code:70037-2809
Mailing Address - Country:US
Mailing Address - Phone:504-377-7242
Mailing Address - Fax:
Practice Address - Street 1:3100 GENERAL DE GAULLE DR
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70114-6632
Practice Address - Country:US
Practice Address - Phone:504-620-3130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA292534164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse