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General NPI Number Information
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NPI Number | 1407522733
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Entity Type | Individual
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Provider Name | LATASHA JACKSON
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Gender | Female
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Dates
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Enumeration Date | 08/17/2021
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Last Update Date | 09/30/2021
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Provider Practice Location Address
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Address Line | 532 BUCKINGHAM PL
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City | DESOTO
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State | TX
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Zip | 75115-6111
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Country | US
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Telephone | 619-846-5650
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Fax |
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Provider Business Mailing Address
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Address Line | 532 BUCKINGHAM PL
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City | DESOTO
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State | TX
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Zip | 75115-6111
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Country | US
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Telephone | 619-846-5650
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 372600000X
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Taxonomy Name | Adult Companion
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License Number |
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License Number State |
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