Healthcare Provider Details

I. General information

NPI: 1124940374
Provider Name (Legal Business Name): LATASHA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6220 WESTPARK DR STE 149J
HOUSTON TX
77057-7371
US

IV. Provider business mailing address

6220 WESTPARK DR STE 149J
HOUSTON TX
77057-7371
US

V. Phone/Fax

Practice location:
  • Phone: 346-329-6224
  • Fax:
Mailing address:
  • Phone: 346-329-6224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: