Provider Demographics
NPI:1669021192
Name:JACKSON, LATOYA
Entity Type:Individual
Prefix:
First Name:LATOYA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LATOYA
Other - Middle Name:
Other - Last Name:MINGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2346 S LYNHURST DR BLDG 100
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46241-5171
Mailing Address - Country:US
Mailing Address - Phone:317-502-1456
Mailing Address - Fax:
Practice Address - Street 1:2346 S LYNHURST DR BLDG 100
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-5171
Practice Address - Country:US
Practice Address - Phone:317-502-1456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-07
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor