Provider Demographics
NPI:1780242693
Name:JACKSON, QUEYSHEINA
Entity type:Individual
Prefix:
First Name:QUEYSHEINA
Middle Name:
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 1:215 HOMEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:RESERVE
Mailing Address - State:LA
Mailing Address - Zip Code:70084-5525
Mailing Address - Country:US
Mailing Address - Phone:985-212-2002
Mailing Address - Fax:
Practice Address - Street 1:215 HOMEWOOD PL
Practice Address - Street 2:
Practice Address - City:RESERVE
Practice Address - State:LA
Practice Address - Zip Code:70084-5525
Practice Address - Country:US
Practice Address - Phone:985-212-2002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health