Provider Demographics
NPI:1568827228
Name:JACKSON, KERMIT
Entity Type:Individual
Prefix:
First Name:KERMIT
Middle Name:
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 1:862 ONEAL LN
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-1874
Mailing Address - Country:US
Mailing Address - Phone:225-362-4539
Mailing Address - Fax:
Practice Address - Street 1:862 ONEAL LN
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816
Practice Address - Country:US
Practice Address - Phone:225-362-4539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-23
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health