Provider Demographics
NPI:1720485121
Name:JACKSON, LATRESA (DMD)
Entity type:Individual
Prefix:
First Name:LATRESA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 CENTRAL PIKE STE 500
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076-3431
Mailing Address - Country:US
Mailing Address - Phone:615-933-7300
Mailing Address - Fax:
Practice Address - Street 1:3901 CENTRAL PIKE STE 500
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-3431
Practice Address - Country:US
Practice Address - Phone:159-337-3006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-01
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY108931223G0001X
TN99571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice