Provider Demographics
NPI:1053774158
Name:JACKSON, BREONKA MARIE
Entity type:Individual
Prefix:
First Name:BREONKA
Middle Name:MARIE
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 1:5220 FOREST PARK LN
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70131-8583
Mailing Address - Country:US
Mailing Address - Phone:504-215-9094
Mailing Address - Fax:
Practice Address - Street 1:615 BARONNE ST STE 304
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70113
Practice Address - Country:US
Practice Address - Phone:504-814-8001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-05
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health