Provider Demographics
NPI:1215624960
Name:JACKSON, LATONYA R
Entity type:Individual
Prefix:MS
First Name:LATONYA
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
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 556
Mailing Address - Street 2:
Mailing Address - City:HAVANA
Mailing Address - State:FL
Mailing Address - Zip Code:32333-0556
Mailing Address - Country:US
Mailing Address - Phone:786-309-3290
Mailing Address - Fax:
Practice Address - Street 1:41 BELL ST
Practice Address - Street 2:
Practice Address - City:HAVANA
Practice Address - State:FL
Practice Address - Zip Code:32333-6300
Practice Address - Country:US
Practice Address - Phone:786-309-3290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL172V00000X, 3747P1801X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No172V00000XOther Service ProvidersCommunity Health Worker
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant