Healthcare Provider Details

I. General information

NPI: 1114848678
Provider Name (Legal Business Name): LAKELIA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42308 WARREN DR
PONCHATOULA LA
70454-8889
US

IV. Provider business mailing address

42308 WARREN DR
PONCHATOULA LA
70454-8889
US

V. Phone/Fax

Practice location:
  • Phone: 504-255-4463
  • Fax:
Mailing address:
  • Phone: 504-255-4463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: