Basic Information
| Provider Information | |||||||||
| NPI: | 1053778894 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | RITA | ||||||||
| MiddleName: | |||||||||
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| Credential: | RSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5417 JACKSON ST | ||||||||
| Address2: | SUITE D | ||||||||
| City: | ALEXANDRIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 713032322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184734328 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5417 JACKSON ST | ||||||||
| Address2: | SUITE D | ||||||||
| City: | ALEXANDRIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 713032322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184734328 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2016 | ||||||||
| LastUpdateDate: | 01/25/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.