Healthcare Provider Details

I. General information

NPI: 1669679403
Provider Name (Legal Business Name): PAUL M JACKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 04/29/2021
Certification Date: 04/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 JEFFERSON HWY
NEW ORLEANS LA
70121-2429
US

IV. Provider business mailing address

1514 JEFFERSON HWY
NEW ORLEANS LA
70121-2429
US

V. Phone/Fax

Practice location:
  • Phone: 504-842-4000
  • Fax:
Mailing address:
  • Phone: 504-842-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberMD.025993
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: