MEDICARE: ANN LYONS JACKSON LMSW

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	104100000X	Social Worker	6465	LA

General Provider Information

NPI Number	:	1699176834
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANN LYONS JACKSON LMSW

Provider Business Mailing Address
First Line	:	PO BOX 395
Second Line	:
City	:	CLINTON
State	:	LA
Zip	:	70722-0395
Country	:	US
Telephone Number	:	225-683-5292
Fax Number	:	225-683-3411

Provider Business Practice Location Address
First Line	:	3170 CHURCH STREET
Second Line	:
City	:	SLAUGHTER
State	:	LA
Zip	:	70777-0000
Country	:	US
Telephone Number	:	225-683-5292
Fax Number	:	225-683-3411

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

Provider Enumeration Date	:	09/08/2014
Last Update Date	:	09/08/2014

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