MEDICARE: MARY D JACKSON LCSW-BAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	12783	LA

General Provider Information

NPI Number	:	1497602817
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY D JACKSON LCSW-BAC

Provider Business Mailing Address
First Line	:	24120 PLANK RD
Second Line	:
City	:	ZACHARY
State	:	LA
Zip	:	70791-6430
Country	:	US
Telephone Number	:	225-620-4132
Fax Number	:

Provider Business Practice Location Address
First Line	:	24120 PLANK RD
Second Line	:
City	:	ZACHARY
State	:	LA
Zip	:	70791-6430
Country	:	US
Telephone Number	:	225-620-4132
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2026
Last Update Date	:	03/13/2026

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