Provider Demographics
NPI:1700192358
Name:JONES, LATARSHA LASHAWN (BSH)
Entity Type:Individual
Prefix:MS
First Name:LATARSHA
Middle Name:LASHAWN
Last Name:JONES
Suffix:
Gender:F
Credentials:BSH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 BENTLEY TRACE LANE NORTH
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257
Mailing Address - Country:US
Mailing Address - Phone:904-955-7500
Mailing Address - Fax:
Practice Address - Street 1:4500 BENTLEY TRACE LN N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-3733
Practice Address - Country:US
Practice Address - Phone:904-955-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-20
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029591400Medicaid