Individual
THAD JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
449 BEN HUR RD APT 5106B, BATON ROUGE, LA 70820-4144
(504) 410-1976
Mailing address
449 BEN HUR RD APT 5106B, BATON ROUGE, LA 70820-4144
(504) 410-1976
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
—
171M00000X
Case Manager/Care Coordinator
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00000
—
LA
Enumeration date
12/26/2017
Last updated
06/16/2018
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