Healthcare Provider Details

I. General information

NPI: 1083299473
Provider Name (Legal Business Name): LAKESHIA WYNETTE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2021
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7505 PINES RD
SHREVEPORT LA
71129-3935
US

IV. Provider business mailing address

937 EDGEFIELD DR
SHREVEPORT LA
71118-3405
US

V. Phone/Fax

Practice location:
  • Phone: 318-683-4086
  • Fax:
Mailing address:
  • Phone: 318-560-8649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: