1790724326 NPI number — DR. SARAH CENAC JACKSON M.D.

Table of content: DR. SARAH CENAC JACKSON M.D. (NPI 1790724326)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790724326 NPI number — DR. SARAH CENAC JACKSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
SARAH
Provider Middle Name:
CENAC
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CENAC
Provider Other First Name:
SARAH
Provider Other Middle Name:
LOUISE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790724326
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3525 PRYTANIA ST
Provider Second Line Business Mailing Address:
SUITE 501
Provider Business Mailing Address City Name:
NEW ORLEANS
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70115-3500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-895-3376
Provider Business Mailing Address Fax Number:
504-910-3350

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3525 PRYTANIA ST
Provider Second Line Business Practice Location Address:
SUITE 501
Provider Business Practice Location Address City Name:
NEW ORLEANS
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70115-3500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-895-3376
Provider Business Practice Location Address Fax Number:
504-910-3350
Provider Enumeration Date:
06/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  026193 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1054691 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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