Healthcare Provider Details

I. General information

NPI: 1881339273
Provider Name (Legal Business Name): TRAVION JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2022
Last Update Date: 04/17/2024
Certification Date: 04/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 HIGHWAY 80 E
MONROE LA
71203-8527
US

IV. Provider business mailing address

206 BOBBY ST
TALLULAH LA
71282-4103
US

V. Phone/Fax

Practice location:
  • Phone: 318-343-8744
  • Fax: 318-345-7123
Mailing address:
  • Phone: 318-341-8147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number012121095
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number5423
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: