Provider Demographics
NPI:1427314517
Name:JACKSON, LATOSHA MARTHIA
Entity type:Individual
Prefix:MS
First Name:LATOSHA
Middle Name:MARTHIA
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 1:2619 N HARVEY AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73103-3017
Mailing Address - Country:US
Mailing Address - Phone:405-525-3959
Mailing Address - Fax:405-525-3439
Practice Address - Street 1:2619 N HARVEY AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103
Practice Address - Country:US
Practice Address - Phone:405-525-3959
Practice Address - Fax:405-525-3439
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health