Provider Demographics
NPI:1033233465
Name:JACKSON, TOMASA LATOYA
Entity Type:Individual
Prefix:
First Name:TOMASA
Middle Name:LATOYA
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:PO BOX 251970
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72225-1970
Mailing Address - Country:US
Mailing Address - Phone:501-666-8686
Mailing Address - Fax:501-660-6830
Practice Address - Street 1:901 PARKER ST
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114-4546
Practice Address - Country:US
Practice Address - Phone:501-374-3686
Practice Address - Fax:501-374-3623
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator