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LASALLE JACKSON
>> Driver >> Other Service ProvidersRegistrant NPI Number: 1508331711
Individual Registrant: LASALLE JACKSON
Gender: M
Not Sole Proprietor
Gender: M
Not Sole Proprietor
Location and contact information for practice:
606 WALNUT ST PORT GIBSON, MS 39150-2140 US
Tel: 601-529-0527 Fax: --
Tel: 601-529-0527 Fax: --
Contact information for business:
606 WALNUT ST PORT GIBSON, MS 39150-2140 US
Tel: 601-529-0527 Fax: --
Tel: 601-529-0527 Fax: --
Registration Information:
NPI: 1508331711
Entity Type: Individual
Entity Type: Individual
Specialty information:
| Primary | Code | Category/Description | State | License Number |
|---|---|---|---|---|
| Y | 172A00000X | Other Service Providers Driver | MS |
Legacy codes, insurance codes and state license numbers:
| Issuer | Number | State | Type |
|---|---|---|---|
