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General NPI Number Information
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NPI Number | 1255657243
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Entity Type | Individual
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Provider Name | TONYA SUE JACKSON PH.D.
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Gender | Female
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Dates
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Enumeration Date | 04/15/2010
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Last Update Date | 12/14/2021
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Provider Practice Location Address
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Address Line | 5411 COLISEUM BLVD
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City | ALEXANDRIA
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State | LA
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Zip | 71303-3729
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Country | US
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Telephone | 318-484-2347
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Fax |
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Provider Business Mailing Address
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Address Line | 3770 MONROE HIGHWAY STE C PMB 170
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City | PINEVILLE
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State | LA
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Zip | 71360-4170
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Country | US
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Telephone | 318-880-3044
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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 | 103TM1800X
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Taxonomy Name | Intellectual & Developmental Disabilities Psychologist
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License Number | 1072
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License Number State | LA
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