Provider Demographics
NPI:1982146668
Name:JACKSON, TROY A
Entity Type:Individual
Prefix:MR
First Name:TROY
Middle Name:A
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 1:1513 LINE AVE SUITE 222
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-6503
Mailing Address - Country:US
Mailing Address - Phone:318-208-8908
Mailing Address - Fax:318-208-8935
Practice Address - Street 1:1513 LINE AVE SUITE 222
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-6503
Practice Address - Country:US
Practice Address - Phone:318-208-8908
Practice Address - Fax:318-208-8935
Is Sole Proprietor?:No
Enumeration Date:2016-11-10
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health