Provider Demographics
NPI:1285852764
Name:JACKSON, KEILON LATRICE (CMA)
Entity Type:Individual
Prefix:MISS
First Name:KEILON
Middle Name:LATRICE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 DOWNING ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-4597
Mailing Address - Country:US
Mailing Address - Phone:678-577-9097
Mailing Address - Fax:
Practice Address - Street 1:511 DOWNING ST
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-4597
Practice Address - Country:US
Practice Address - Phone:678-577-9097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA20019336068372600000X, 374U00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No372600000XNursing Service Related ProvidersAdult Companion
No376K00000XNursing Service Related ProvidersNurse's Aide