Provider Demographics
NPI:1356894919
Name:JACKSON, KE'ARRAH
Entity type:Individual
Prefix:
First Name:KE'ARRAH
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 NATALIE PARK DR
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-8439
Mailing Address - Country:US
Mailing Address - Phone:985-360-8199
Mailing Address - Fax:
Practice Address - Street 1:4266 WEST MAIN STREET SUITE 100
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:LA
Practice Address - Zip Code:70359
Practice Address - Country:US
Practice Address - Phone:985-360-8199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-01
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor