MEDICARE: GERMAINE RONKEITH 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	164W00000X	Licensed Practical Nurse	20121157	LA

General Provider Information

NPI Number	:	1861984890
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GERMAINE RONKEITH JACKSON

Provider Business Mailing Address
First Line	:	637 OAKWOOD DR
Second Line	:
City	:	GRETNA
State	:	LA
Zip	:	70056-2932
Country	:	US
Telephone Number	:	504-729-0299
Fax Number	:

Provider Business Practice Location Address
First Line	:	5555 BULLARD AVE
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70128-3450
Country	:	US
Telephone Number	:	504-240-2696
Fax Number	:

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

Provider Enumeration Date	:	06/05/2018
Last Update Date	:	06/05/2018

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