Provider Demographics
NPI:1891208823
Name:JACKSON, MODEACON LATRELL SR
Entity Type:Individual
Prefix:
First Name:MODEACON
Middle Name:LATRELL
Last Name:JACKSON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 BERNSTEIN PARK RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71202-5502
Mailing Address - Country:US
Mailing Address - Phone:318-331-3440
Mailing Address - Fax:
Practice Address - Street 1:1702 BERNSTEIN PARK RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202-5502
Practice Address - Country:US
Practice Address - Phone:318-331-3440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health