MEDICARE: QUAKEITHA JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1285129130
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	QUAKEITHA JACKSON

Provider Business Mailing Address
First Line	:	124 KIMBROUGH BLVD BLDG Q124
Second Line	:
City	:	TALLULAH
State	:	LA
Zip	:	71282-4307
Country	:	US
Telephone Number	:	318-574-4400
Fax Number	:

Provider Business Practice Location Address
First Line	:	124 KIMBROUGH BLVD BLDG Q124
Second Line	:
City	:	TALLULAH
State	:	LA
Zip	:	71282-4307
Country	:	US
Telephone Number	:	318-574-4400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2018
Last Update Date	:	06/23/2018

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