Provider Demographics
NPI:1891206116
Name:JACKSON, RICHARD WARREN JR (LCSW-BACS, LAC, CCGC)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:WARREN
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:LCSW-BACS, LAC, CCGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7732 GOODWOOD BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-7680
Mailing Address - Country:US
Mailing Address - Phone:504-517-6390
Mailing Address - Fax:
Practice Address - Street 1:7732 GOODWOOD BLVD STE 102
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-7680
Practice Address - Country:US
Practice Address - Phone:504-517-6390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-13
Last Update Date:2023-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA136301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical