Provider Demographics
NPI:1760016380
Name:JACKSON, UNGELA
Entity Type:Individual
Prefix:
First Name:UNGELA
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 1:2800 YOUREE DR STE 350
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-3646
Mailing Address - Country:US
Mailing Address - Phone:318-210-0928
Mailing Address - Fax:
Practice Address - Street 1:2800 YOUREE DR STE 350
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-3646
Practice Address - Country:US
Practice Address - Phone:318-210-0928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator