Healthcare Provider Details

I. General information

NPI: 1245153485
Provider Name (Legal Business Name): ROBERT JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4079 CLEMATIS ST
NEW ORLEANS LA
70122-4870
US

IV. Provider business mailing address

4079 CLEMATIS ST
NEW ORLEANS LA
70122-4870
US

V. Phone/Fax

Practice location:
  • Phone: 803-201-2706
  • Fax:
Mailing address:
  • Phone: 803-201-2706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number205741
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: