Provider Demographics
NPI:1679058382
Name:JACKSON, CRYSTAL
Entity type:Individual
Prefix:
First Name:CRYSTAL
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 1:5000 WOODLAND DR APT 207
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70131-7614
Mailing Address - Country:US
Mailing Address - Phone:504-231-5496
Mailing Address - Fax:
Practice Address - Street 1:6305 ELYSIAN FIELDS AVE STE 404
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70122-4293
Practice Address - Country:US
Practice Address - Phone:504-265-0996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty