Healthcare Provider Details

I. General information

NPI: 1063694768
Provider Name (Legal Business Name): ERIN JACKSON DICHARRY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2551 GREENWOOD RD STE 410
SHREVEPORT LA
71103-3989
US

IV. Provider business mailing address

PO BOX 51008
SHREVEPORT LA
71135-1008
US

V. Phone/Fax

Practice location:
  • Phone: 318-621-2929
  • Fax: 318-621-2930
Mailing address:
  • Phone: 318-798-9400
  • Fax: 318-798-6785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number200154
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: