Provider Demographics
NPI:1336656305
Name:JACKSON, SHARLAYNE
Entity Type:Individual
Prefix:
First Name:SHARLAYNE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHARLAYNE
Other - Middle Name:JACKSON
Other - Last Name:PREVOST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:341 LATIGUE RD
Mailing Address - Street 2:
Mailing Address - City:WESTWEGO
Mailing Address - State:LA
Mailing Address - Zip Code:70094-2360
Mailing Address - Country:US
Mailing Address - Phone:832-474-5534
Mailing Address - Fax:504-324-0878
Practice Address - Street 1:6217 WESTBANK EXPY
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-2858
Practice Address - Country:US
Practice Address - Phone:832-474-5534
Practice Address - Fax:504-324-0878
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-29
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health