Provider Demographics
NPI:1265801708
Name:JACKSON, LASHAWN (MS)
Entity type:Individual
Prefix:
First Name:LASHAWN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 NOB HILL CT NW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35810-3706
Mailing Address - Country:US
Mailing Address - Phone:256-348-5139
Mailing Address - Fax:
Practice Address - Street 1:203 EASTSIDE SQ
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-8818
Practice Address - Country:US
Practice Address - Phone:256-274-0382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-15
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL330000014Medicaid