Provider Demographics
NPI:1881339273
Name:JACKSON, TRAVION
Entity type:Individual
Prefix:
First Name:TRAVION
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 BOBBY ST
Mailing Address - Street 2:
Mailing Address - City:TALLULAH
Mailing Address - State:LA
Mailing Address - Zip Code:71282-4103
Mailing Address - Country:US
Mailing Address - Phone:318-341-8147
Mailing Address - Fax:
Practice Address - Street 1:645 HIGHWAY 80 E
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-8527
Practice Address - Country:US
Practice Address - Phone:318-343-8744
Practice Address - Fax:318-345-7123
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-01
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA012121095101YA0400X
LA5423171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)