Provider Demographics
NPI:1346872363
Name:JACKSON, CHARLOTTE CORMIER (LPC, NCC)
Entity Type:Individual
Prefix:MRS
First Name:CHARLOTTE
Middle Name:CORMIER
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 E SAINT PETER ST
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-3752
Mailing Address - Country:US
Mailing Address - Phone:337-321-9204
Mailing Address - Fax:337-321-9210
Practice Address - Street 1:449 E SAINT PETER ST
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560-3752
Practice Address - Country:US
Practice Address - Phone:337-321-9204
Practice Address - Fax:337-321-9210
Is Sole Proprietor?:No
Enumeration Date:2020-02-07
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
LA8002101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator