Provider Demographics
NPI:1144786211
Name:JACKSON, PORSHA MARIE (RSW)
Entity Type:Individual
Prefix:MRS
First Name:PORSHA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RSW
Other - Prefix:MISS
Other - First Name:PORSHA
Other - Middle Name:MARIE
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RSW
Mailing Address - Street 1:502 E COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-4512
Mailing Address - Country:US
Mailing Address - Phone:318-533-0741
Mailing Address - Fax:
Practice Address - Street 1:1204 STUBBS AVE STE B
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5631
Practice Address - Country:US
Practice Address - Phone:318-582-5633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15200171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator