Provider Demographics
NPI:1912136797
Name:JACKOSN, LATOYA T (COUNSELOR)
Entity Type:Individual
Prefix:
First Name:LATOYA
Middle Name:T
Last Name:JACKOSN
Suffix:
Gender:F
Credentials:COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20420 TERRELL ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-3209
Mailing Address - Country:US
Mailing Address - Phone:313-218-2626
Mailing Address - Fax:
Practice Address - Street 1:SUNSHINE TREATMENT IN
Practice Address - Street 2:4821 E. MCNICHOLS
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48212
Practice Address - Country:US
Practice Address - Phone:313-368-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-14
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJ250488789675101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor