Provider Demographics
NPI:1619325362
Name:JACKSON, LATICIA (MPH)
Entity Type:Individual
Prefix:
First Name:LATICIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 BAYOU BLVD
Mailing Address - Street 2:SUITE 47 B3
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2673
Mailing Address - Country:US
Mailing Address - Phone:850-696-8069
Mailing Address - Fax:
Practice Address - Street 1:4400 BAYOU BLVD
Practice Address - Street 2:SUITE 47B3
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2673
Practice Address - Country:US
Practice Address - Phone:850-696-8069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator