Provider Demographics
NPI:1669228516
Name:JACKSON, LATASHA ANNETTE
Entity type:Individual
Prefix:MS
First Name:LATASHA
Middle Name:ANNETTE
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 1:880 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14605-1442
Mailing Address - Country:US
Mailing Address - Phone:585-267-6819
Mailing Address - Fax:
Practice Address - Street 1:880 NORTH ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14605-1442
Practice Address - Country:US
Practice Address - Phone:585-267-6819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344007164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse