Provider Demographics
NPI:1104104413
Name:CLAIBORNE, LATASHA JACKSON (PMHNP)
Entity type:Individual
Prefix:MRS
First Name:LATASHA
Middle Name:JACKSON
Last Name:CLAIBORNE
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:MRS
Other - First Name:LATASHA
Other - Middle Name:JACKSON
Other - Last Name:CLAIBORRNE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:1701 WHITE ST
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648
Mailing Address - Country:US
Mailing Address - Phone:601-249-4214
Mailing Address - Fax:601-249-1062
Practice Address - Street 1:3444 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5331
Practice Address - Country:US
Practice Address - Phone:601-638-0031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-03
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904842363LP0808X
MS163W00000X163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health