Provider Demographics
NPI:1871035311
Name:JACKSON, JANISA LEANN
Entity Type:Individual
Prefix:
First Name:JANISA
Middle Name:LEANN
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 1:2525 YOUREE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-3671
Mailing Address - Country:US
Mailing Address - Phone:318-742-3408
Mailing Address - Fax:
Practice Address - Street 1:203 E ACADEMY AVE
Practice Address - Street 2:SECOND LEVEL SUITES
Practice Address - City:JENNINGS
Practice Address - State:LA
Practice Address - Zip Code:70546-5331
Practice Address - Country:US
Practice Address - Phone:337-824-1255
Practice Address - Fax:337-824-1257
Is Sole Proprietor?:No
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor