Provider Demographics
NPI:1104532290
Name:JACKSON, KAI'DARYIA D (RSW)
Entity type:Individual
Prefix:
First Name:KAI'DARYIA
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 EE WALLACE BLVD N
Mailing Address - Street 2:
Mailing Address - City:FERRIDAY
Mailing Address - State:LA
Mailing Address - Zip Code:71334-2209
Mailing Address - Country:US
Mailing Address - Phone:318-452-4338
Mailing Address - Fax:318-437-7096
Practice Address - Street 1:701 EE WALLACE BLVD N
Practice Address - Street 2:
Practice Address - City:FERRIDAY
Practice Address - State:LA
Practice Address - Zip Code:71334-2209
Practice Address - Country:US
Practice Address - Phone:318-452-4338
Practice Address - Fax:318-437-7096
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator