Provider Demographics
NPI:1861984890
Name:JACKSON, GERMAINE RONKEITH
Entity type:Individual
Prefix:
First Name:GERMAINE
Middle Name:RONKEITH
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056-2932
Mailing Address - Country:US
Mailing Address - Phone:504-729-0299
Mailing Address - Fax:
Practice Address - Street 1:5555 BULLARD AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70128-3450
Practice Address - Country:US
Practice Address - Phone:504-240-2696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA20121157164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse