Provider Demographics
NPI:1679549836
Name:JACKSON, HENRY A (MD)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4224 HOUMA BLVD 380
Mailing Address - Street 2:EJ PULMONARY MEDICINE EJPULM
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-2980
Mailing Address - Country:US
Mailing Address - Phone:504-454-5213
Mailing Address - Fax:504-456-8053
Practice Address - Street 1:4224 HOUMA BLVD STE 380
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-2980
Practice Address - Country:US
Practice Address - Phone:504-454-5213
Practice Address - Fax:504-456-8053
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL010098207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1129054Medicaid
LA5K028Medicare ID - Type Unspecified
LA1129054Medicaid