Provider Demographics
NPI:1467280925
Name:JACKSON, JANICE L
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:L
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:PO BOX 7934
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39506-7934
Mailing Address - Country:US
Mailing Address - Phone:228-343-6608
Mailing Address - Fax:
Practice Address - Street 1:3911 BELMEDE DR
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-3158
Practice Address - Country:US
Practice Address - Phone:228-343-6608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-24
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral