Provider Demographics
NPI:1033576244
Name:JACKSON, MYISHA MYERS
Entity Type:Individual
Prefix:
First Name:MYISHA
Middle Name:MYERS
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MYISHA
Other - Middle Name:
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:801 STUBBS AVE STE D
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5566
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 STUBBS AVE STE D
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5566
Practice Address - Country:US
Practice Address - Phone:318-582-5147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-19
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX88456101Y00000X
101Y00000X
LA6912101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor