Healthcare Provider Details

I. General information

NPI: 1972856805
Provider Name (Legal Business Name): MRS. QUE'ANA LACHE MORRIS JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2012
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

931 MONROE DR NE STE A102-450
ATLANTA GA
30308-1793
US

IV. Provider business mailing address

PO BOX 16294
ATLANTA GA
30321-0294
US

V. Phone/Fax

Practice location:
  • Phone: 404-789-4079
  • Fax: 877-833-3855
Mailing address:
  • Phone: 404-789-4079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code102X00000X
TaxonomyPoetry Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: