Healthcare Provider Details

I. General information

NPI: 1215631676
Provider Name (Legal Business Name): LATOSHA MARIE JACKSON HAIR STYLIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 03/31/2023
Certification Date: 03/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3710 GRANT DR STE A
RENO NV
89509-5317
US

IV. Provider business mailing address

250 KARSTEN CT
RENO NV
89506-5630
US

V. Phone/Fax

Practice location:
  • Phone: 775-786-0885
  • Fax:
Mailing address:
  • Phone: 775-770-8023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: