Provider Demographics
NPI:1902532179
Name:JACKSON, LATASHA
Entity Type:Individual
Prefix:
First Name:LATASHA
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 1:3831 SW 31ST CT
Mailing Address - Street 2:
Mailing Address - City:WEST PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33023-5744
Mailing Address - Country:US
Mailing Address - Phone:754-230-2585
Mailing Address - Fax:
Practice Address - Street 1:3831 SW 31ST CT
Practice Address - Street 2:
Practice Address - City:WEST PARK
Practice Address - State:FL
Practice Address - Zip Code:33023-5744
Practice Address - Country:US
Practice Address - Phone:754-230-2585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No174200000XOther Service ProvidersMeals
No332U00000XSuppliersHome Delivered Meals
No342000000XTransportation ServicesTransportation Network Company
No372600000XNursing Service Related ProvidersAdult Companion
No376J00000XNursing Service Related ProvidersHomemaker