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NPI Code Detail

MEDICARE: KENNETH DAVID JACKSON JR. CSW

MEDICARE: KENNETH DAVID JACKSON JR. CSW
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
1101YM0800XMental Health Counselor17790LA
2171M00000XCase Manager/Care Coordinator
3104100000XSocial Worker17790LA

General Provider Information

NPI Number : 1942674411
Entity Type Code : Individual
Provider Name (Legal Business Name) : KENNETH DAVID JACKSON JR. CSW
Provider Business Mailing Address
First Line : 3901 ULLOA ST
Second Line :
City : NEW ORLEANS
State : LA
Zip : 70119-6942
Country : US
Telephone Number : 504-267-5712
Fax Number : 504-267-5714
Provider Business Practice Location Address
First Line : 3901 ULLOA ST
Second Line :
City : NEW ORLEANS
State : LA
Zip : 70119-6942
Country : US
Telephone Number : 504-267-5712
Fax Number : 504-267-5714
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/21/2015
Last Update Date : 05/08/2025

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