Basic Information
| Provider Information | |||||||||
| NPI: | 1053851063 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | ANDRIA | ||||||||
| MiddleName: | DANIELL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1616 ARKANSAS RD APT 169 | ||||||||
| Address2: | |||||||||
| City: | WEST MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712917042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2108802621 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 CHINABERRY DR STE 900 | ||||||||
| Address2: | |||||||||
| City: | BOSSIER CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711112455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182594676 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2017 | ||||||||
| LastUpdateDate: | 07/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.