Provider Demographics
NPI:1770228389
Name:JACKSON-RODRIGUEZ, LATASHA R (MA)
Entity Type:Individual
Prefix:MS
First Name:LATASHA
Middle Name:R
Last Name:JACKSON-RODRIGUEZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1012
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98035-1012
Mailing Address - Country:US
Mailing Address - Phone:253-398-1547
Mailing Address - Fax:
Practice Address - Street 1:407 W GOWE ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-5806
Practice Address - Country:US
Practice Address - Phone:253-398-1547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-28
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60497444106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty