MEDICARE: PAIGE HEWLETT JACKSON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA12713	TX
2	363A00000X	Physician Assistant	301790	LA

General Provider Information

NPI Number	:	1942672282
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAIGE HEWLETT JACKSON PA-C

Provider Business Mailing Address
First Line	:	382 ALDEN BRIDGE LOOP
Second Line	:
City	:	BENTON
State	:	LA
Zip	:	71006-8618
Country	:	US
Telephone Number	:	318-218-6712
Fax Number	:

Provider Business Practice Location Address
First Line	:	1605 BENTON RD
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-3578
Country	:	US
Telephone Number	:	318-716-3814
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/27/2015
Last Update Date	:	10/01/2024

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