Provider Demographics
NPI:1063840262
Name:JACKSON, LATESHIA
Entity Type:Individual
Prefix:
First Name:LATESHIA
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 1:8142 HAROLD CT
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-4960
Mailing Address - Country:US
Mailing Address - Phone:202-253-3588
Mailing Address - Fax:
Practice Address - Street 1:8737 BROOKS DR STE 108
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-7474
Practice Address - Country:US
Practice Address - Phone:800-867-2395
Practice Address - Fax:410-443-4960
Is Sole Proprietor?:No
Enumeration Date:2013-10-24
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR193593363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health