Provider Demographics
NPI:1811412448
Name:JACKSON, WEALTHIA LYNA (LICENSED SCHOOL PSYC)
Entity Type:Individual
Prefix:MRS
First Name:WEALTHIA
Middle Name:LYNA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LICENSED SCHOOL PSYC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11115 SANDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:KEITHVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71047-8345
Mailing Address - Country:US
Mailing Address - Phone:318-393-6935
Mailing Address - Fax:
Practice Address - Street 1:11115 SANDWOOD DR
Practice Address - Street 2:
Practice Address - City:KEITHVILLE
Practice Address - State:LA
Practice Address - Zip Code:71047-8345
Practice Address - Country:US
Practice Address - Phone:318-393-6935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALSSP009103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool