Provider Demographics
NPI:1417628090
Name:JACKSON, CHARLETTA WILLIAMS (MA/CNA)
Entity Type:Individual
Prefix:MS
First Name:CHARLETTA
Middle Name:WILLIAMS
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA/CNA
Other - Prefix:
Other - First Name:CHARLETTA
Other - Middle Name:W
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA/CNA
Mailing Address - Street 1:9151 INTERLINE AVE STE 5-B
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-1970
Mailing Address - Country:US
Mailing Address - Phone:225-444-5096
Mailing Address - Fax:833-926-1772
Practice Address - Street 1:9151 INTERLINE AVE STE 5-B
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-1970
Practice Address - Country:US
Practice Address - Phone:225-444-5096
Practice Address - Fax:833-926-1772
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA313120376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
LANAOtherNA