Individual
MICAELA SHANTA JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1003 HUGH WALLIS RD S STE B2, LAFAYETTE, LA 70508-2528
(337) 205-4444
Mailing address
21600 OXNARD ST STE 1800, WOODLAND HILLS, CA 91367-7807
(818) 345-2345
(000) 000-0000
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
106S00000X
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
7678808059517
—
LA
Enumeration date
04/20/2019
Last updated
04/20/2019
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