Provider Demographics
NPI:1477992188
Name:JACKSON, LATOSHA M (LICSW)
Entity Type:Individual
Prefix:
First Name:LATOSHA
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:LATOSHA
Other - Middle Name:M
Other - Last Name:DUESTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:1 HARDY RD # 128
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-4915
Mailing Address - Country:US
Mailing Address - Phone:402-469-6899
Mailing Address - Fax:
Practice Address - Street 1:6 CHENELL DR STE 100
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-8514
Practice Address - Country:US
Practice Address - Phone:402-469-6899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2108101YM0800X
NE18221041C0700X
NH21381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health