Provider Demographics
NPI:1780150029
Name:JACKSON, SHAWANDA E
Entity type:Individual
Prefix:
First Name:SHAWANDA
Middle Name:E
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 1:11258 REGENCY AVENUE
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403
Mailing Address - Country:US
Mailing Address - Phone:985-402-5500
Mailing Address - Fax:
Practice Address - Street 1:303 VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-4723
Practice Address - Country:US
Practice Address - Phone:225-250-9654
Practice Address - Fax:225-412-3820
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-14
Last Update Date:2018-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst