Provider Demographics
NPI:1184076630
Name:JACKSON, LISA M (PLPC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 JOHN WATLEY RD
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-7021
Mailing Address - Country:US
Mailing Address - Phone:318-332-3502
Mailing Address - Fax:
Practice Address - Street 1:210 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-6052
Practice Address - Country:US
Practice Address - Phone:318-357-3122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-08
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
LA7749101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator