Provider Demographics
NPI:1669987236
Name:JACKSON, LATRINA COLLEEN (RN)
Entity type:Individual
Prefix:
First Name:LATRINA
Middle Name:COLLEEN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4922 WINDY HILL DR STE A
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-5196
Mailing Address - Country:US
Mailing Address - Phone:984-200-9993
Mailing Address - Fax:844-747-4505
Practice Address - Street 1:4922 WINDY HILL DR STE A
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-5196
Practice Address - Country:US
Practice Address - Phone:984-200-9993
Practice Address - Fax:844-747-4505
Is Sole Proprietor?:No
Enumeration Date:2017-12-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC210120163WC0400X, 163WI0500X, 163WP0808X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health