Provider Demographics
NPI:1205279478
Name:ERICA B. JACKSON, M.D., LLC
Entity type:Organization
Organization Name:ERICA B. JACKSON, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:BROWN
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-305-4232
Mailing Address - Street 1:214 LAUREL OAK DR
Mailing Address - Street 2:
Mailing Address - City:SAINT ROSE
Mailing Address - State:LA
Mailing Address - Zip Code:70087-3241
Mailing Address - Country:US
Mailing Address - Phone:504-717-5454
Mailing Address - Fax:
Practice Address - Street 1:2002 20TH ST
Practice Address - Street 2:SUITE A101
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70062-6289
Practice Address - Country:US
Practice Address - Phone:504-305-4232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-08
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD 200224207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty