Provider Demographics
NPI:1508259367
Name:JACKSON, LATREESE
Entity Type:Individual
Prefix:
First Name:LATREESE
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 1:2049 AMBER SWEET CIR
Mailing Address - Street 2:
Mailing Address - City:DUNDEE
Mailing Address - State:FL
Mailing Address - Zip Code:33838-4271
Mailing Address - Country:US
Mailing Address - Phone:407-701-8201
Mailing Address - Fax:
Practice Address - Street 1:2049 AMBER SWEET CIR
Practice Address - Street 2:
Practice Address - City:DUNDEE
Practice Address - State:FL
Practice Address - Zip Code:33838-4271
Practice Address - Country:US
Practice Address - Phone:407-701-8201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-17
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
No372600000XNursing Service Related ProvidersAdult Companion