Provider Demographics
NPI:1205542107
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 1:5135 DEVERON ST STE B
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-7530
Mailing Address - Country:US
Mailing Address - Phone:919-740-8056
Mailing Address - Fax:
Practice Address - Street 1:5135 DEVERON ST STE B
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7530
Practice Address - Country:US
Practice Address - Phone:252-406-0576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-25
Last Update Date:2025-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747P1801X
NCHC7950253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant