Provider Demographics
NPI:1831999408
Name:JACKSON, LATANYA (HEALTHCARE ADMIN)
Entity type:Individual
Prefix:MRS
First Name:LATANYA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:HEALTHCARE ADMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4033 WISDOM WAY
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-8343
Mailing Address - Country:US
Mailing Address - Phone:615-293-6350
Mailing Address - Fax:
Practice Address - Street 1:4033 WISDOM WAY
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-8343
Practice Address - Country:US
Practice Address - Phone:615-293-6350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-13
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care