Provider Demographics
NPI:1497275036
Name:WIGGINS, JACKSON K (LCSW)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:K
Last Name:WIGGINS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 SHERLING AVE
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2225
Mailing Address - Country:US
Mailing Address - Phone:312-498-8634
Mailing Address - Fax:
Practice Address - Street 1:2400 CANAL ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-6535
Practice Address - Country:US
Practice Address - Phone:800-935-8387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-25
Last Update Date:2017-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA112551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical