Most Relevant Information
Provider Data
| NPI Number: | 1003329160 |
| Provider Name: | STACI NICOLE JACKSON |
| Entity Type: | Individual |
| Taxonomy Code: | 101YM0800X |
| Specialty: | Counselor |
| License Number: |
Most Important Dates
| Enumeration Date: | 11/13/2017 |
| Last Updated: | 11/13/2017 |
Provider Practice Location
11616 SOUTHFORK AVE
BATON ROUGE
LA
708165241
Practice Location Phone/Fax
| Phone: | 2252919646 |
| Fax: |
Provider Mailing Location
11616 SOUTHFORK AVE
BATON ROUGE
LA
708165241
Provider Mailing Phone/Fax
| Phone: | 2252919646 |
| Fax: |