Provider Demographics
NPI:1083079511
Name:JACKSON, TITANIA
Entity Type:Individual
Prefix:
First Name:TITANIA
Middle Name:
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 1:115 BACLE DR
Mailing Address - Street 2:
Mailing Address - City:CAMPTI
Mailing Address - State:LOUISIANA
Mailing Address - Zip Code:71411
Mailing Address - Country:UM
Mailing Address - Phone:318-609-2776
Mailing Address - Fax:
Practice Address - Street 1:610 N LOOP 336 E
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77301-1437
Practice Address - Country:US
Practice Address - Phone:281-742-1142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-29
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101YM0800X
TX685811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health