Healthcare Provider Details

I. General information

NPI: 1346763463
Provider Name (Legal Business Name): AUDREA KELLAR JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3888 S SHERWOOD FOREST BLVD STE F
BATON ROUGE LA
70816
US

IV. Provider business mailing address

3888 S SHERWOOD FOREST BLVD STE F
BATON ROUGE LA
70816-4400
US

V. Phone/Fax

Practice location:
  • Phone: 225-771-8251
  • Fax:
Mailing address:
  • Phone: 225-771-8251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: