Healthcare Provider Details

I. General information

NPI: 1144786211
Provider Name (Legal Business Name): PORSHA MARIE JACKSON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PORSHA MARIE KENNEDY RSW

II. Dates (important events)

Enumeration Date: 02/14/2019
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3455 FLORIDA ST STE 400
BATON ROUGE LA
70806-3764
US

IV. Provider business mailing address

11361 N 99TH AVE STE 402
PEORIA AZ
85345-5459
US

V. Phone/Fax

Practice location:
  • Phone: 225-256-6604
  • Fax: 225-256-2553
Mailing address:
  • Phone: 602-650-1212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number15200
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: