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General NPI Number Information
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NPI Number | 1861984890
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Entity Type | Individual
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Provider Name | GERMAINE RONKEITH JACKSON
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Gender | Male
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Dates
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Enumeration Date | 06/05/2018
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Last Update Date | 06/05/2018
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Provider Practice Location Address
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Address Line | 5555 BULLARD AVE
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City | NEW ORLEANS
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State | LA
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Zip | 70128-3450
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Country | US
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Telephone | 504-240-2696
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Fax |
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Provider Business Mailing Address
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Address Line | 637 OAKWOOD DR
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City | GRETNA
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State | LA
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Zip | 70056-2932
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Country | US
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Telephone | 504-729-0299
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | 20121157
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License Number State | LA
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