Provider Demographics
NPI:1760857700
Name:JACKO, TALISHA
Entity Type:Individual
Prefix:
First Name:TALISHA
Middle Name:
Last Name:JACKO
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 1:840 W BAYOU PINES DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-7495
Mailing Address - Country:US
Mailing Address - Phone:337-491-1740
Mailing Address - Fax:337-491-1741
Practice Address - Street 1:840 W BAYOU PINES DR
Practice Address - Street 2:SUITE B
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601
Practice Address - Country:US
Practice Address - Phone:337-491-1740
Practice Address - Fax:337-491-1741
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-02
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health