Healthcare Provider Details

I. General information

NPI: 1942882345
Provider Name (Legal Business Name): MS. SANQUANITA CHARNAE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. SANQUANITA CHARNAE JACKSON

II. Dates (important events)

Enumeration Date: 04/25/2021
Last Update Date: 12/23/2025
Certification Date: 12/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 N 18TH ST
MONROE LA
71201-4432
US

IV. Provider business mailing address

1900 N 18TH ST
MONROE LA
71201-4432
US

V. Phone/Fax

Practice location:
  • Phone: 318-600-6838
  • Fax:
Mailing address:
  • Phone: 318-600-6838
  • Fax: 318-600-6837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number011332403
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: