Provider Demographics
NPI:1356022388
Name:JACKSON, LASHARAE MECHELLE
Entity type:Individual
Prefix:
First Name:LASHARAE
Middle Name:MECHELLE
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 1:14410 BAILEY CT
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92394-3205
Mailing Address - Country:US
Mailing Address - Phone:442-284-2778
Mailing Address - Fax:
Practice Address - Street 1:14410 BAILEY CT
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92394-3205
Practice Address - Country:US
Practice Address - Phone:442-284-2778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula