Provider Demographics
NPI:1912658238
Name:JACKSON, MARCUS GEORGE
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:GEORGE
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 1:3925 N I 10 SERVICE RD W STE 117
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-6831
Mailing Address - Country:US
Mailing Address - Phone:504-455-2446
Mailing Address - Fax:
Practice Address - Street 1:3925 N I 10 SERVICE RD W STE 117
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-6831
Practice Address - Country:US
Practice Address - Phone:504-455-2446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-18
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOBHPSS856175T00000X
LANA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health