Provider Demographics
NPI:1194297036
Name:JACKSON, GIANNA LATRICE (GMFT)
Entity type:Individual
Prefix:MS
First Name:GIANNA
Middle Name:LATRICE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:GMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 644
Mailing Address - Street 2:
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20757-0644
Mailing Address - Country:US
Mailing Address - Phone:619-944-9971
Mailing Address - Fax:
Practice Address - Street 1:2255 CRAIN HWY STE 107
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-3186
Practice Address - Country:US
Practice Address - Phone:301-292-2778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA223042164X00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No164X00000XNursing Service ProvidersLicensed Vocational Nurse