Healthcare Provider Details

I. General information

NPI: 1053774158
Provider Name (Legal Business Name): BREONKA MARIE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2016
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 BARONNE ST STE 304
NEW ORLEANS LA
70113
US

IV. Provider business mailing address

5220 FOREST PARK LN
NEW ORLEANS LA
70131-8583
US

V. Phone/Fax

Practice location:
  • Phone: 504-814-8001
  • Fax:
Mailing address:
  • Phone: 504-215-9094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: