Provider Demographics
NPI:1063851848
Name:THOMAS, LATESHA W (LCSW)
Entity type:Individual
Prefix:MS
First Name:LATESHA
Middle Name:W
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 W WOODROW WILSON AVENUE
Mailing Address - Street 2:SUITE #3140
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-7664
Mailing Address - Country:US
Mailing Address - Phone:769-251-5751
Mailing Address - Fax:
Practice Address - Street 1:350 W WOODROW WILSON AVENUE
Practice Address - Street 2:SUITE #3140
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213
Practice Address - Country:US
Practice Address - Phone:769-251-5751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC79401041C0700X
TX58101104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker