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NPI Code Detail

MEDICARE: GERELLE G JACKSON

MEDICARE: GERELLE G 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
1103K00000XBehavior Analyst

General Provider Information

NPI Number : 1831549393
Entity Type Code : Individual
Provider Name (Legal Business Name) : GERELLE G JACKSON
Provider Business Mailing Address
First Line : 3173 WASHINGTON AVE
Second Line :
City : BATON ROUGE
State : LA
Zip : 70802-2178
Country : US
Telephone Number : 225-778-7678
Fax Number : 225-341-6825
Provider Business Practice Location Address
First Line : 3173 WASHINGTON AVE
Second Line :
City : BATON ROUGE
State : LA
Zip : 70802-2178
Country : US
Telephone Number : 225-778-7678
Fax Number : 225-341-6825
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/15/2016
Last Update Date : 02/06/2019

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