Provider Demographics
NPI:1952910846
Name:JACKSON, PATRICE QUINETTE
Entity Type:Individual
Prefix:MRS
First Name:PATRICE
Middle Name:QUINETTE
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 1:7274 MODESTO AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70811-4427
Mailing Address - Country:US
Mailing Address - Phone:225-288-7917
Mailing Address - Fax:
Practice Address - Street 1:7274 MODESTO AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70811-4427
Practice Address - Country:US
Practice Address - Phone:225-288-7917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA005562615172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver