Healthcare Provider Details

I. General information

NPI: 1013391176
Provider Name (Legal Business Name): KENDRICK JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2015
Last Update Date: 07/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 CHURCH ST
NATCHITOCHES LA
71457-4612
US

IV. Provider business mailing address

311 CHURCH ST
NATCHITOCHES LA
71457-4612
US

V. Phone/Fax

Practice location:
  • Phone: 318-451-6011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateLA
# 5
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateLA
# 6
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateLA
# 7
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number StateLA
# 8
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateLA
# 9
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateLA
# 10
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: