Provider Demographics
NPI:1932682358
Name:JACKSON, EVIAN MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:EVIAN
Middle Name:MICHELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:EVIAN
Other - Middle Name:MICHELLE
Other - Last Name:GOODE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9655 JUDI AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70815-4923
Mailing Address - Country:US
Mailing Address - Phone:225-938-4445
Mailing Address - Fax:
Practice Address - Street 1:4055 PRESCOTT RD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70805-5146
Practice Address - Country:US
Practice Address - Phone:225-372-2037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA8233235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA010354707Medicaid