Provider Demographics
NPI:1295891562
Name:JACKSON, REGINALD (SOCIAL WORKER)
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:SOCIAL WORKER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 872382
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70187-2382
Mailing Address - Country:US
Mailing Address - Phone:504-813-6258
Mailing Address - Fax:504-368-2180
Practice Address - Street 1:7425 EDWARD ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70126-2013
Practice Address - Country:US
Practice Address - Phone:504-813-6258
Practice Address - Fax:504-368-2180
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4522101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health