Provider Demographics
NPI:1598063083
Name:JACKSON, LATONYA C
Entity Type:Individual
Prefix:MRS
First Name:LATONYA
Middle Name:C
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 1:121 SIMS ST
Mailing Address - Street 2:
Mailing Address - City:SIMSBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71275-3208
Mailing Address - Country:US
Mailing Address - Phone:318-247-8439
Mailing Address - Fax:318-242-4698
Practice Address - Street 1:121 SIMS ST
Practice Address - Street 2:
Practice Address - City:SIMSBORO
Practice Address - State:LA
Practice Address - Zip Code:71275-3208
Practice Address - Country:US
Practice Address - Phone:318-247-8439
Practice Address - Fax:318-242-4698
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-07
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor