Provider Demographics
NPI:1437921715
Name:JACKSON, LATRESHA
Entity Type:Individual
Prefix:
First Name:LATRESHA
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 1:7758 PLEASANT VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28075-6699
Mailing Address - Country:US
Mailing Address - Phone:704-277-9996
Mailing Address - Fax:
Practice Address - Street 1:7758 PLEASANT VALLEY DR
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:NC
Practice Address - Zip Code:28075-6699
Practice Address - Country:US
Practice Address - Phone:704-277-9996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC183196163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty