Provider Demographics
NPI:1720868409
Name:JACKSON, LATASHA MARIE
Entity type:Individual
Prefix:
First Name:LATASHA
Middle Name:MARIE
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 1:2259 OLD VILLA RICA RD
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-1506
Mailing Address - Country:US
Mailing Address - Phone:216-507-8284
Mailing Address - Fax:
Practice Address - Street 1:2259 OLD VILLA RICA RD
Practice Address - Street 2:
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-1506
Practice Address - Country:US
Practice Address - Phone:216-507-8284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No372500000XNursing Service Related ProvidersChore Provider
No376J00000XNursing Service Related ProvidersHomemaker
No385H00000XRespite Care FacilityRespite Care