Provider Demographics
NPI:1477797009
Name:JACKSON, DONNA MARIE
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:MARIE
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 7792
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70010-7792
Mailing Address - Country:US
Mailing Address - Phone:504-944-2012
Mailing Address - Fax:
Practice Address - Street 1:8080 CROWDER BLVD STE E
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70127-1077
Practice Address - Country:US
Practice Address - Phone:504-823-4989
Practice Address - Fax:504-831-7712
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-27
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA103K00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst