Provider Demographics
NPI:1952641805
Name:JACKSON, NATASHA V
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:V
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 CROSSGATES BLVD APT 226
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-2560
Mailing Address - Country:US
Mailing Address - Phone:601-813-6141
Mailing Address - Fax:
Practice Address - Street 1:180 SHEPPARD RD STE 115
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-4033
Practice Address - Country:US
Practice Address - Phone:601-813-6141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC81251041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty