Provider Demographics
NPI:1235700998
Name:JACKSON, LEDASHA (MS)
Entity type:Individual
Prefix:
First Name:LEDASHA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30656-4791
Mailing Address - Country:US
Mailing Address - Phone:678-558-3056
Mailing Address - Fax:
Practice Address - Street 1:1035 WINDSOR DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30656-4791
Practice Address - Country:US
Practice Address - Phone:678-558-3056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-05
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health