Healthcare Provider Details

I. General information

NPI: 1063840262
Provider Name (Legal Business Name): LATESHIA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2013
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8737 BROOKS DR STE 108
EASTON MD
21601-7474
US

IV. Provider business mailing address

8142 HAROLD CT
GLEN BURNIE MD
21061-4960
US

V. Phone/Fax

Practice location:
  • Phone: 800-867-2395
  • Fax: 410-443-4960
Mailing address:
  • Phone: 202-253-3588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR193593
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: