Provider Demographics
NPI:1558072421
Name:JACKSON, LATANYA (PBT)
Entity Type:Individual
Prefix:
First Name:LATANYA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PBT
Other - Prefix:
Other - First Name:LATANYA
Other - Middle Name:
Other - Last Name:JEMISON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1897 EISENHOWER RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-9583
Mailing Address - Country:US
Mailing Address - Phone:615-300-3724
Mailing Address - Fax:
Practice Address - Street 1:315 PROVIDENCE BLVD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-4325
Practice Address - Country:US
Practice Address - Phone:615-300-3724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-12
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN67093246R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246R00000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Pathology