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General NPI Number Information
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NPI Number | 1114459666
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Entity Type | Individual
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Provider Name | ALTRECIA L JACKSON LPN
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Gender | Female
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Dates
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Enumeration Date | 04/03/2017
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Last Update Date | 01/03/2019
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Provider Practice Location Address
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Address Line | 7209 LOUISE ST
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City | SHREVEPORT
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State | LA
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Zip | 71108-4844
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Country | US
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Telephone | 318-344-8365
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Fax |
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Provider Business Mailing Address
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Address Line | 3341 YOUREE DRIVE
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City | SHREVEPORT
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State | LA
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Zip | 71105
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Country | US
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Telephone | 318-344-8365
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | 880566
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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