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Individual

MATTHEW JACKSON

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
Man

Contact information

Practice address
3121 JOHNSTON ST APT 142, LAFAYETTE, LA 70503-3760
(337) 201-2365
(337) 419-0513
Mailing address
3121 JOHNSTON ST APT 142, LAFAYETTE, LA 70503-3760

Taxonomy

Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
010460855
LA

Other

Enumeration date
06/08/2016
Last updated
06/08/2016
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