=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629456496
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEATHA JACKSON LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2015
-----------------------------------------------------
Last Update Date | 09/18/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11990 JACKSON ST
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70722-3210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-683-5292
-----------------------------------------------------
Fax | 225-683-3411
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25733 BLACKWELL RD
-----------------------------------------------------
City | ANGIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70426-4017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 9337
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 9337
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------