Provider Demographics
NPI:1588847594
Name:JACKSON, LA TOYA (LCSW)
Entity type:Individual
Prefix:MS
First Name:LA TOYA
Middle Name:
Last Name:JACKSON
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 1:412 DARTER DR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-5088
Mailing Address - Country:US
Mailing Address - Phone:678-401-2538
Mailing Address - Fax:
Practice Address - Street 1:180 WATER OAK DR
Practice Address - Street 2:HIGHLAND RIVERS
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-2095
Practice Address - Country:US
Practice Address - Phone:770-748-0030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-12
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1160361041C0700X
GACSW0044231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical