Provider Demographics
NPI:1750710174
Name:JACKSON, LATONYA DEMETRIA (CAC II)
Entity type:Individual
Prefix:MRS
First Name:LATONYA
Middle Name:DEMETRIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CAC II
Other - Prefix:
Other - First Name:LATONYA
Other - Middle Name:DETERIMA
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CAC II
Mailing Address - Street 1:2711 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6818
Mailing Address - Country:US
Mailing Address - Phone:803-726-9300
Mailing Address - Fax:
Practice Address - Street 1:2711 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6818
Practice Address - Country:US
Practice Address - Phone:803-726-9300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)