Provider Demographics
NPI:1912935578
Name:JSK PROFESSIONAL PHYSICIAN SERVICES, LLC
Entity Type:Organization
Organization Name:JSK PROFESSIONAL PHYSICIAN SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KESSELS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-871-6088
Mailing Address - Street 1:PO BOX 54528
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70154-4528
Mailing Address - Country:US
Mailing Address - Phone:985-845-9000
Mailing Address - Fax:985-845-9003
Practice Address - Street 1:16300 HIGHWAY 1085
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7227
Practice Address - Country:US
Practice Address - Phone:985-871-6088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CQ10Medicare ID - Type UnspecifiedMEDICARE GROUP #