Provider Demographics
NPI:1376292672
Name:JACKSON, LATONYA
Entity Type:Individual
Prefix:
First Name:LATONYA
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 1:108 FLETCHER DR
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71049-3035
Mailing Address - Country:US
Mailing Address - Phone:318-871-7217
Mailing Address - Fax:
Practice Address - Street 1:108 FLETCHER DR
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:LA
Practice Address - Zip Code:71049-3035
Practice Address - Country:US
Practice Address - Phone:318-871-7217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide