Provider Demographics
NPI:1205200680
Name:JACKSON, LATIA SADE
Entity Type:Individual
Prefix:
First Name:LATIA
Middle Name:SADE
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 1:230 S HEWITT RD
Mailing Address - Street 2:APT 204
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-4487
Mailing Address - Country:US
Mailing Address - Phone:989-746-4360
Mailing Address - Fax:
Practice Address - Street 1:230 S HEWITT RD
Practice Address - Street 2:APT 204
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-4487
Practice Address - Country:US
Practice Address - Phone:989-746-4360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-22
Last Update Date:2015-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI247200000OtherTECHNICIAN