Provider Demographics
NPI:1154826444
Name:JACKSON, MYRIKLE ALESIA (BACHELOR OF SCIENCE)
Entity Type:Individual
Prefix:MS
First Name:MYRIKLE
Middle Name:ALESIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:BACHELOR OF SCIENCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:862 ONEAL LN
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-1874
Mailing Address - Country:US
Mailing Address - Phone:225-275-3039
Mailing Address - Fax:
Practice Address - Street 1:862 ONEAL LN
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-1874
Practice Address - Country:US
Practice Address - Phone:225-275-3039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA101YM0800XMedicaid