Provider Demographics
NPI:1053592600
Name:JACKSON STREET MEDICAL CENTER
Entity type:Organization
Organization Name:JACKSON STREET MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:G
Authorized Official - Last Name:ZAVALETA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-445-0129
Mailing Address - Street 1:5623 JACKSON STREET EXT
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-2326
Mailing Address - Country:US
Mailing Address - Phone:318-455-0129
Mailing Address - Fax:318-443-3284
Practice Address - Street 1:5623 JACKSON STREET EXT
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-2326
Practice Address - Country:US
Practice Address - Phone:318-455-0129
Practice Address - Fax:318-443-3284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-23
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12742R261QF0050X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAH08679Medicare UPIN