Basic Information
Provider Information | |||||||||
NPI: | 1164948899 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACKSON | ||||||||
FirstName: | NAOMI | ||||||||
MiddleName: | JEFFERSON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MATTHEWS | ||||||||
OtherFirstName: | NAOMI | ||||||||
OtherMiddleName: | JEFFERSON | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2525 YOUREE DR. SUITE 110 | ||||||||
Address2: |   | ||||||||
City: | SHREVEPORT | ||||||||
State: | LA | ||||||||
PostalCode: | 71104 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3187423408 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1333 COMMON ST | ||||||||
Address2: |   | ||||||||
City: | LAKE CHARLES | ||||||||
State: | LA | ||||||||
PostalCode: | 706015255 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3374374014 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/15/2017 | ||||||||
LastUpdateDate: | 03/23/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/23/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | Y |   | Other Service Providers | Case Manager/Care Coordinator |   |
No ID Information.