Provider Demographics
NPI:1952510398
Name:JACKSON, LATOYA (MS,QP)
Entity Type:Individual
Prefix:
First Name:LATOYA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS,QP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 HOLLAND DR
Mailing Address - Street 2:
Mailing Address - City:CASTLE HAYNE
Mailing Address - State:NC
Mailing Address - Zip Code:28429-5914
Mailing Address - Country:US
Mailing Address - Phone:313-468-7794
Mailing Address - Fax:
Practice Address - Street 1:5041 NEW CENTRE DR STE 209
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-1624
Practice Address - Country:US
Practice Address - Phone:910-392-8956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor