Healthcare Provider Details

I. General information

NPI: 1164391439
Provider Name (Legal Business Name): KRYSTAL LYNN JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2025
Last Update Date: 11/04/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 LAFAYETTE ST
GRETNA LA
70053-5732
US

IV. Provider business mailing address

2340 EASTMERE ST
HARVEY LA
70058-2215
US

V. Phone/Fax

Practice location:
  • Phone: 504-533-9152
  • Fax:
Mailing address:
  • Phone: 504-481-3946
  • Fax: 504-481-3946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: