=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821167263
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BYRON ANDRA JACKSON MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2006
-----------------------------------------------------
Last Update Date | 05/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 653 W 70TH ST
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71106-2949
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-636-8389
-----------------------------------------------------
Fax | 318-636-8389
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 740012
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30374-0012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-352-1515
-----------------------------------------------------
Fax | 312-929-0373
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 08028R
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------