Provider Demographics
NPI:1528568672
Name:JACKSON, JOHNELL CALVIN
Entity Type:Individual
Prefix:MR
First Name:JOHNELL
Middle Name:CALVIN
Last Name:JACKSON
Suffix:
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 1:3501 CAESAR DR
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70114-9211
Mailing Address - Country:US
Mailing Address - Phone:504-505-8864
Mailing Address - Fax:
Practice Address - Street 1:3501 CAESAR DR
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70114-9211
Practice Address - Country:US
Practice Address - Phone:504-505-8864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health