Provider Demographics
NPI:1942672282
Name:JACKSON, PAIGE HEWLETT (PA-C)
Entity type:Individual
Prefix:
First Name:PAIGE
Middle Name:HEWLETT
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:PAIGE
Other - Middle Name:
Other - Last Name:HEWLETT MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:382 ALDEN BRIDGE LOOP
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:LA
Mailing Address - Zip Code:71006-8618
Mailing Address - Country:US
Mailing Address - Phone:318-218-6712
Mailing Address - Fax:
Practice Address - Street 1:1605 BENTON RD
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3578
Practice Address - Country:US
Practice Address - Phone:318-716-3814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-27
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12713363A00000X
LA301790363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant