Individual
MS. CHANDRA ALISA JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MHP
Contact information
Practice address
1058 E WORTHY ST STE B-2, GONZALES, LA 70737-4302
(225) 450-3216
(225) 450-3799
Mailing address
1058 E WORTHY ST STE B-2, GONZALES, LA 70737-4302
(225) 450-3216
(225) 450-3799
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1366981557
—
LA
Enumeration date
11/02/2017
Last updated
09/23/2019
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