Provider Demographics
NPI:1275800997
Name:JACKSON, LATRICE VERNICE
Entity Type:Individual
Prefix:
First Name:LATRICE
Middle Name:VERNICE
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 1:1415 E 10TH ST
Mailing Address - Street 2:2425 LENORE ST.
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-7801
Mailing Address - Country:US
Mailing Address - Phone:405-382-7623
Mailing Address - Fax:
Practice Address - Street 1:1415 E 10TH ST
Practice Address - Street 2:2425 LENORE ST.
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-7801
Practice Address - Country:US
Practice Address - Phone:405-382-7623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-23
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health