Healthcare Provider Details

I. General information

NPI: 1568973402
Provider Name (Legal Business Name): TIFFANI JACKSON RSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2017
Last Update Date: 12/27/2024
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 3RD ST
NATCHITOCHES LA
71457-4602
US

IV. Provider business mailing address

605 ELVIRA DR
NATCHITOCHES LA
71457-3666
US

V. Phone/Fax

Practice location:
  • Phone: 318-238-8801
  • Fax: 318-238-8803
Mailing address:
  • Phone: 985-750-6839
  • Fax: 318-238-8801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number7104
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: