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?CodeTypeClassificationSpecializationGroup
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral Health
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No372600000XNursing Service Related ProvidersAdult Companion
No373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Multi-Specialty