Basic Information
| Provider Information | |||||||||
| NPI: | 1881339273 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | TRAVION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 206 BOBBY ST | ||||||||
| Address2: | |||||||||
| City: | TALLULAH | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712824103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183418147 | ||||||||
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| Practice Location | |||||||||
| Address1: | 645 HIGHWAY 80 E | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712038527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183438744 | ||||||||
| FaxNumber: | 3183457123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2022 | ||||||||
| LastUpdateDate: | 05/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 012121095 | LA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.