Provider Demographics
NPI:1720451685
Name:JACKSON, ALFREDA T
Entity Type:Individual
Prefix:
First Name:ALFREDA
Middle Name:T
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 1:833 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-3535
Mailing Address - Country:US
Mailing Address - Phone:337-519-1682
Mailing Address - Fax:
Practice Address - Street 1:116 BERTRAND DR
Practice Address - Street 2:STE 100
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506
Practice Address - Country:US
Practice Address - Phone:337-519-1682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-01
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator