Healthcare Provider Details

I. General information

NPI: 1912658238
Provider Name (Legal Business Name): MARCUS GEORGE JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2022
Last Update Date: 05/31/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3925 N I 10 SERVICE RD W STE 117
METAIRIE LA
70002-6831
US

IV. Provider business mailing address

3925 N I 10 SERVICE RD W STE 117
METAIRIE LA
70002-6831
US

V. Phone/Fax

Practice location:
  • Phone: 504-455-2446
  • Fax:
Mailing address:
  • Phone: 504-455-2446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberNA
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberOBHPSS856
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: