Provider Demographics
NPI:1720885155
Name:JACKSON, LATOSHA
Entity type:Individual
Prefix:
First Name:LATOSHA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10603 JUNIPER BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:ROSHARON
Mailing Address - State:TX
Mailing Address - Zip Code:77583-4216
Mailing Address - Country:US
Mailing Address - Phone:510-853-4896
Mailing Address - Fax:
Practice Address - Street 1:10603 JUNIPER BRANCH DR
Practice Address - Street 2:
Practice Address - City:ROSHARON
Practice Address - State:TX
Practice Address - Zip Code:77583-4216
Practice Address - Country:US
Practice Address - Phone:510-853-4896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-25
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1180974363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health