Provider Demographics
NPI:1962788380
Name:JACKOSN, LATORYA
Entity type:Individual
Prefix:
First Name:LATORYA
Middle Name:
Last Name:JACKOSN
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 1:196 LEE ROAD 956
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:AL
Mailing Address - Zip Code:36874-2886
Mailing Address - Country:US
Mailing Address - Phone:334-363-0950
Mailing Address - Fax:
Practice Address - Street 1:2100 COMER AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-8725
Practice Address - Country:US
Practice Address - Phone:334-363-0950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator