Provider Demographics
NPI:1053914754
Name:JACKSON, LAVAR
Entity type:Individual
Prefix:
First Name:LAVAR
Middle Name:
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 1:820 ANNANDALE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-7827
Mailing Address - Country:US
Mailing Address - Phone:504-250-1316
Mailing Address - Fax:
Practice Address - Street 1:820 ANNANDALE RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-7827
Practice Address - Country:US
Practice Address - Phone:504-250-1316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker