Provider Demographics
NPI:1134590672
Name:JACKSON, FREDERICKA
Entity type:Individual
Prefix:
First Name:FREDERICKA
Middle Name:
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 1:2688 OLD TOWNE DR
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-2777
Mailing Address - Country:US
Mailing Address - Phone:225-993-5993
Mailing Address - Fax:
Practice Address - Street 1:9550 UNITED PLAZA BLVD
Practice Address - Street 2:STE 702 -N
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-0200
Practice Address - Country:US
Practice Address - Phone:954-603-7885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst