Basic Information
Provider Information | |||||||||
NPI: | 1336378140 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACKSON | ||||||||
FirstName: | MARQUITA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4506 HIGHWAY 952 | ||||||||
Address2: |   | ||||||||
City: | JACKSON | ||||||||
State: | LA | ||||||||
PostalCode: | 707483130 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2254545283 | ||||||||
FaxNumber: | 2256834354 | ||||||||
Practice Location | |||||||||
Address1: | 11990 JACKSON ST. | ||||||||
Address2: |   | ||||||||
City: | CLINTON | ||||||||
State: | LA | ||||||||
PostalCode: | 70722 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2256835292 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2009 | ||||||||
LastUpdateDate: | 07/14/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WS0200X | RN112654 | LA | Y |   | Nursing Service Providers | Registered Nurse | School |
No ID Information.