Provider Demographics
NPI:1972856805
Name:MORRIS JACKSON, QUE'ANA LACHE
Entity Type:Individual
Prefix:MRS
First Name:QUE'ANA
Middle Name:LACHE
Last Name:MORRIS 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:PO BOX 16294
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30321-0294
Mailing Address - Country:US
Mailing Address - Phone:404-789-4079
Mailing Address - Fax:
Practice Address - Street 1:931 MONROE DR NE STE A102-450
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-1793
Practice Address - Country:US
Practice Address - Phone:404-789-4079
Practice Address - Fax:877-833-3855
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No102X00000XBehavioral Health & Social Service ProvidersPoetry Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172A00000XOther Service ProvidersDriver
No174H00000XOther Service ProvidersHealth Educator
No175F00000XOther Service ProvidersNaturopath
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1972856805Medicaid