Provider Demographics
NPI:1144958646
Name:LATHAN JONES, TRUDY
Entity type:Individual
Prefix:
First Name:TRUDY
Middle Name:
Last Name:LATHAN JONES
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 1:3862 N 54TH BLVD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-2206
Mailing Address - Country:US
Mailing Address - Phone:414-254-4909
Mailing Address - Fax:
Practice Address - Street 1:5622 N 65TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-2328
Practice Address - Country:US
Practice Address - Phone:414-254-4909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities