Healthcare Provider Details

I. General information

NPI: 1184076630
Provider Name (Legal Business Name): LISA M JACKSON PLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2016
Last Update Date: 04/29/2022
Certification Date: 12/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 MEDICAL DR
NATCHITOCHES LA
71457-6052
US

IV. Provider business mailing address

408 JOHN WATLEY RD
NATCHITOCHES LA
71457-7021
US

V. Phone/Fax

Practice location:
  • Phone: 318-357-3122
  • Fax:
Mailing address:
  • Phone: 318-332-3502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7749
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: