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Provider Information for 1417244286


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Ms. GWENDOLYN SANDRA JACKSON L.C.S.W.


Sex: Female

NPI: 1417244286
Last Updated: 2011-06-30
Certification Date:

Details

NameValue
NPI1417244286
Enumeration Date2011-06-30
NPI TypeNPI-1 Individual
Sole ProprietorYES
StatusActive
Mailing Address PO BOX 538
BAKER, LA 70704-0538
United States

Phone: 225-205-1581 | Fax:
 
Primary Practice Address 2514 GATES CIR APT 12
BATON ROUGE, LA 70809-1017
United States

Phone: 225-205-1581 | Fax:
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
Yes 1041C0700X - Social Worker - ClinicalLA3189