Provider Demographics
NPI:1306394234
Name:JACKSON HANDS OF CHANGE
Entity Type:Organization
Organization Name:JACKSON HANDS OF CHANGE
Other - Org Name:COMMUNITY MENTAL HEALTH CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DREATHA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPS-S, NCC
Authorized Official - Phone:618-623-9771
Mailing Address - Street 1:4807 EVANGELINE ST
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001-4415
Mailing Address - Country:US
Mailing Address - Phone:618-623-9771
Mailing Address - Fax:
Practice Address - Street 1:4035 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70125-2935
Practice Address - Country:US
Practice Address - Phone:618-623-9771
Practice Address - Fax:877-250-2283
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACKSON HANDS OF CHANGE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-20
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA251S00000X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health