Provider Demographics
NPI:1952886939
Name:JACKSON, DLISA
Entity type:Individual
Prefix:
First Name:DLISA
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 1:140 LEIGH LN
Mailing Address - Street 2:
Mailing Address - City:MONTZ
Mailing Address - State:LA
Mailing Address - Zip Code:70068-8968
Mailing Address - Country:US
Mailing Address - Phone:504-205-3355
Mailing Address - Fax:
Practice Address - Street 1:200 S BROAD ST STE 7
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-6447
Practice Address - Country:US
Practice Address - Phone:504-205-3355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty