Provider Demographics
NPI:1952965840
Name:JACKSON, LABRINTARY
Entity Type:Individual
Prefix:
First Name:LABRINTARY
Middle Name:
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 1:119 HERMAN JOHNSON W
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:MS
Mailing Address - Zip Code:38751-3664
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:119 HERMAN JOHNSON W
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:MS
Practice Address - Zip Code:38751-3664
Practice Address - Country:US
Practice Address - Phone:662-452-6006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS172A00000X, 174200000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Multi-Specialty
No172A00000XOther Service ProvidersDriverGroup - Multi-Specialty
No174200000XOther Service ProvidersMealsGroup - Multi-Specialty