Individual
TANYA TALITA JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
4201 N I 10 SERVICE RD W, METAIRIE, LA 70006-6713
(888) 880-9270
Mailing address
6402 BRIDGEHAMPTON DR, NEW ORLEANS, LA 70126-1517
(504) 236-6438
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
600846883
—
LA
Enumeration date
09/14/2016
Last updated
11/06/2018
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