Provider Demographics
NPI:1952172835
Name:JACKSON, DANIELLE JENKINS
Entity Type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:JENKINS
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 1:525 HIGHWAY 306
Mailing Address - Street 2:
Mailing Address - City:PARADIS
Mailing Address - State:LA
Mailing Address - Zip Code:70080-2617
Mailing Address - Country:US
Mailing Address - Phone:504-931-0190
Mailing Address - Fax:
Practice Address - Street 1:4202 N. I-10 SERVICE RD W.
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006
Practice Address - Country:US
Practice Address - Phone:877-418-2978
Practice Address - Fax:866-500-2186
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician