Provider Demographics
NPI:1720485121
Name:JACKSON, LATRESA (DMD)
Entity Type:Individual
Prefix:DR
First Name:LATRESA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:KY
Mailing Address - Zip Code:42220-8812
Mailing Address - Country:US
Mailing Address - Phone:270-330-0008
Mailing Address - Fax:
Practice Address - Street 1:810 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:KY
Practice Address - Zip Code:42220-8812
Practice Address - Country:US
Practice Address - Phone:270-330-0008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-01
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN99571223G0001X
KY108931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice