Provider Demographics
NPI:1205454774
Name:JACKSON STREET PEDIATRICS, LLC
Entity type:Organization
Organization Name:JACKSON STREET PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAI
Authorized Official - Middle Name:A
Authorized Official - Last Name:WICKER-BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-300-3637
Mailing Address - Street 1:6326 WINDY OAKS
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-2966
Mailing Address - Country:US
Mailing Address - Phone:313-300-3637
Mailing Address - Fax:
Practice Address - Street 1:5716 JACKSON ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-2042
Practice Address - Country:US
Practice Address - Phone:318-767-6503
Practice Address - Fax:318-703-8257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty