Provider Demographics
NPI:1942050059
Name:JACKSON, MICHAEL LATRELLE
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LATRELLE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1156 BANNOCKBURN AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-1095
Mailing Address - Country:US
Mailing Address - Phone:803-718-5292
Mailing Address - Fax:
Practice Address - Street 1:1156 BANNOCKBURN AVE
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1095
Practice Address - Country:US
Practice Address - Phone:803-718-5292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCIHCP-2092374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide