Provider Demographics
NPI:1942882345
Name:JACKSON, SANQUANITA CHARNAE
Entity Type:Individual
Prefix:MS
First Name:SANQUANITA
Middle Name:CHARNAE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SANQUANITA
Other - Middle Name:CHARNAE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:9403 MANSFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3815
Mailing Address - Country:US
Mailing Address - Phone:318-861-0381
Mailing Address - Fax:
Practice Address - Street 1:9403 MANSFIELD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3815
Practice Address - Country:US
Practice Address - Phone:318-861-8938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-25
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
LA011332403171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty