Healthcare Provider Details

I. General information

NPI: 1689629891
Provider Name (Legal Business Name): HOWARD WOODROW JACKSON JR. R.D.C.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 08/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W BOUNDARY AVE
WINNFIELD LA
71483-3427
US

IV. Provider business mailing address

25 KANOME ROAD
LECOMPTE LA
71346-9566
US

V. Phone/Fax

Practice location:
  • Phone: 318-648-3064
  • Fax: 318-628-3285
Mailing address:
  • Phone: 318-776-9949
  • Fax: 413-653-8834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246XS1301X
TaxonomySonography Specialist/Technologist Cardiovascular
License Number16604
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: