Healthcare Provider Details

I. General information

NPI: 1669987236
Provider Name (Legal Business Name): LATRINA COLLEEN JACKSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4922 WINDY HILL DR STE A
RALEIGH NC
27609-5196
US

IV. Provider business mailing address

4922 WINDY HILL DR STE A
RALEIGH NC
27609-5196
US

V. Phone/Fax

Practice location:
  • Phone: 984-200-9993
  • Fax: 844-747-4505
Mailing address:
  • Phone: 984-200-9993
  • Fax: 844-747-4505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number210120
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number210120
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number210120
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number210120
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: