Provider Demographics
NPI:1801963483
Name:JACKSON, DREATHA JEAN (MA, LPC, NCC)
Entity type:Individual
Prefix:MRS
First Name:DREATHA
Middle Name:JEAN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:DREATHA
Other - Middle Name:JEAN
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LPC, NCC
Mailing Address - Street 1:406 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-4329
Mailing Address - Country:US
Mailing Address - Phone:618-623-9771
Mailing Address - Fax:
Practice Address - Street 1:6032 PONTCHARTRAIN BLVD
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70124-1934
Practice Address - Country:US
Practice Address - Phone:618-623-9771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6130101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO495864829Medicaid
MO495864803Medicaid