Provider Demographics
NPI:1356998231
Name:JACKSON, KAMERON NICHOLAS
Entity type:Individual
Prefix:
First Name:KAMERON
Middle Name:NICHOLAS
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 PECAN ST APT 52
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70401-2380
Mailing Address - Country:US
Mailing Address - Phone:985-215-2084
Mailing Address - Fax:
Practice Address - Street 1:901 PECAN ST APT 52
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401-2380
Practice Address - Country:US
Practice Address - Phone:985-215-2084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-24
Last Update Date:2019-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA010944287106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician