Healthcare Provider Details

I. General information

NPI: 1871055129
Provider Name (Legal Business Name): LATOSHA JACKSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2019
Last Update Date: 04/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5539 S 27TH ST STE 104
LINCOLN NE
68512-1600
US

IV. Provider business mailing address

5539 S 27TH ST STE 104
LINCOLN NE
68512-1600
US

V. Phone/Fax

Practice location:
  • Phone: 402-261-8313
  • Fax:
Mailing address:
  • Phone: 402-261-8313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: LATOSHA M JACKSON
Title or Position: LICENSED CLINICIAN SOCIAL WORKER
Credential: LIMHP, CMSW
Phone: 402-469-6899