Provider Demographics
NPI:1801369111
Name:JACKSON, LATASHA (LPN)
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:LATASHA
Other - Middle Name:
Other - Last Name:JACKSON SCOTT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4573 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-6309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4573 N 22ND ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-6309
Practice Address - Country:US
Practice Address - Phone:414-517-2825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31744531164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse