MEDICARE: MS. TIFFANI JACKSON RSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator
2	104100000X	Social Worker	7104	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0	OTHER	LA	N/A

General Provider Information

NPI Number	:	1568973402
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TIFFANI JACKSON RSW

Provider Business Mailing Address
First Line	:	605 ELVIRA DR
Second Line	:
City	:	NATCHITOCHES
State	:	LA
Zip	:	71457-3666
Country	:	US
Telephone Number	:	985-750-6839
Fax Number	:	318-238-8801

Provider Business Practice Location Address
First Line	:	714 3RD ST
Second Line	:
City	:	NATCHITOCHES
State	:	LA
Zip	:	71457-4602
Country	:	US
Telephone Number	:	318-238-8801
Fax Number	:	318-238-8803

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2017
Last Update Date	:	12/27/2024

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