Basic Information
| Provider Information | |||||||||
| NPI: | 1386000735 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | JEWEL | ||||||||
| MiddleName: | PAMELA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3625 YOUREE DR | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711052121 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 8326 KELWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708064803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259299738 | ||||||||
| FaxNumber: | 2259299740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2016 | ||||||||
| LastUpdateDate: | 07/22/2019 | ||||||||
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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 | 101YP2500X | 825 | LA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.