Provider Demographics
NPI:1679087308
Name:JACKSON, JOHNALYNN
Entity Type:Individual
Prefix:
First Name:JOHNALYNN
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 1:11760 S HARRELLS FERRY RD STE C
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-2374
Mailing Address - Country:US
Mailing Address - Phone:225-284-8671
Mailing Address - Fax:
Practice Address - Street 1:11760 S HARRELLS FERRY RD STE C
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-2374
Practice Address - Country:US
Practice Address - Phone:225-284-8671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-16
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health