Provider Demographics
NPI:1255657243
Name:JACKSON, TONYA SUE (PHD)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:SUE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3770 MONROE HIGHWAY STE C
Mailing Address - Street 2:PMB 170
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-4170
Mailing Address - Country:US
Mailing Address - Phone:318-880-3044
Mailing Address - Fax:
Practice Address - Street 1:5411 COLISEUM BLVD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-3729
Practice Address - Country:US
Practice Address - Phone:318-484-2347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-15
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1072103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities