Provider Demographics
NPI:1508309055
Name:JACKSON, ANDREW III
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:JACKSON
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 HUDSON LN
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-6068
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1401 HUDSON LN
Practice Address - Street 2:SUITE 202
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-6068
Practice Address - Country:US
Practice Address - Phone:318-570-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-30
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1306217062OtherMENTAL HEALTH