Provider Demographics
NPI:1306344148
Name:JACKSON, PATSY MARIE (MHP)
Entity type:Individual
Prefix:
First Name:PATSY
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 HIGHWAY 154
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:LA
Mailing Address - Zip Code:71003-3103
Mailing Address - Country:US
Mailing Address - Phone:318-278-0256
Mailing Address - Fax:318-263-9703
Practice Address - Street 1:847 HIGHWAY 154
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:LA
Practice Address - Zip Code:71003-3103
Practice Address - Country:US
Practice Address - Phone:318-278-0256
Practice Address - Fax:318-263-9703
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health