Provider Demographics
NPI:1891152773
Name:JACKSON, JOSEPH GRANVILLE (CCS, RAC)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:GRANVILLE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CCS, RAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 SPARROW ST
Mailing Address - Street 2:
Mailing Address - City:LAKE PROVIDENCE
Mailing Address - State:LA
Mailing Address - Zip Code:71254-3520
Mailing Address - Country:US
Mailing Address - Phone:318-559-3356
Mailing Address - Fax:318-559-2044
Practice Address - Street 1:411 SPARROW ST
Practice Address - Street 2:
Practice Address - City:LAKE PROVIDENCE
Practice Address - State:LA
Practice Address - Zip Code:71254-3035
Practice Address - Country:US
Practice Address - Phone:318-559-3356
Practice Address - Fax:318-559-2044
Is Sole Proprietor?:No
Enumeration Date:2016-01-22
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA186101YA0400X
LA1300101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)