Provider Demographics
NPI:1023358041
Name:JACKSON, CRYSTAL J
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4946 TANQUERAY LN APT B
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-1321
Mailing Address - Country:US
Mailing Address - Phone:317-417-8221
Mailing Address - Fax:
Practice Address - Street 1:2626 CHARLES DR
Practice Address - Street 2:
Practice Address - City:CHALMETTE
Practice Address - State:LA
Practice Address - Zip Code:70043-3779
Practice Address - Country:US
Practice Address - Phone:504-278-4006
Practice Address - Fax:504-278-4007
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-28
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker