Provider Demographics
NPI:1598118705
Name:JACKSON, SHENQUIE
Entity Type:Individual
Prefix:
First Name:SHENQUIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 THOMAS H DELPIT DR STE 125
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70802-6626
Mailing Address - Country:US
Mailing Address - Phone:225-636-2395
Mailing Address - Fax:225-960-2984
Practice Address - Street 1:1520 THOMAS H DELPIT DR STE 125
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70802
Practice Address - Country:US
Practice Address - Phone:225-636-2395
Practice Address - Fax:225-960-2984
Is Sole Proprietor?:No
Enumeration Date:2016-07-22
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
LA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health