Provider Demographics
NPI: | 1922500289 |
---|---|
Name: | JACKSON, LATORIA NICOLE |
Entity Type: | Individual |
Prefix: | |
First Name: | LATORIA |
Middle Name: | NICOLE |
Last Name: | JACKSON |
Suffix: | |
Gender: | F |
Credentials: | |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 4150 ALEXIS CT |
Mailing Address - Street 2: | |
Mailing Address - City: | LOGANVILLE |
Mailing Address - State: | GA |
Mailing Address - Zip Code: | 30052-9070 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 678-671-0078 |
Mailing Address - Fax: | 888-948-2083 |
Practice Address - Street 1: | 4150 ALEXIS CT |
Practice Address - Street 2: | |
Practice Address - City: | LOGANVILLE |
Practice Address - State: | GA |
Practice Address - Zip Code: | 30052-9070 |
Practice Address - Country: | US |
Practice Address - Phone: | 678-671-0078 |
Practice Address - Fax: | 888-948-2083 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2018-03-02 |
Last Update Date: | 2018-03-02 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 343900000X | Transportation Services | Non-emergency Medical Transport (VAN) | ||
No | 171M00000X | Other Service Providers | Case Manager/Care Coordinator | Group - Multi-Specialty | |
No | 251B00000X | Agencies | Case Management | ||
No | 251C00000X | Agencies | Day Training, Developmentally Disabled Services | ||
No | 251S00000X | Agencies | Community/Behavioral Health | ||
No | 261QA0600X | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care | |
No | 261QD1600X | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities | |
No | 3104A0625X | Nursing & Custodial Care Facilities | Assisted Living Facility | Assisted Living, Mental Illness | |
No | 320600000X | Residential Treatment Facilities | Residential Treatment Facility, Intellectual and/or Developmental Disabilities | ||
No | 320900000X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities | ||
No | 372600000X | Nursing Service Related Providers | Adult Companion | ||
No | 373H00000X | Nursing Service Related Providers | Day Training/Habilitation Specialist | Group - Multi-Specialty |