Provider Demographics
NPI:1164391439
Name:JACKSON, KRYSTAL LYNN
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:LYNN
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 1:2340 EASTMERE ST
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70058-2215
Mailing Address - Country:US
Mailing Address - Phone:504-481-3946
Mailing Address - Fax:504-481-3946
Practice Address - Street 1:1500 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70053-5732
Practice Address - Country:US
Practice Address - Phone:504-533-9152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-04
Last Update Date:2025-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261QM0801X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)