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General NPI Number Information
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NPI Number | 1477992188
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Entity Type | Individual
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Provider Name | LATOSHA M JACKSON LICSW
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Gender | Female
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Dates
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Enumeration Date | 06/17/2013
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Last Update Date | 12/23/2021
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Provider Practice Location Address
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Address Line | 6 CHENELL DR STE 100
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City | CONCORD
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State | NH
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Zip | 03301-8514
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Country | US
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Telephone | 402-469-6899
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Fax |
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Provider Business Mailing Address
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Address Line | 1 HARDY RD # 128
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City | BEDFORD
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State | NH
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Zip | 03110-4915
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Country | US
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Telephone | 402-469-6899
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 2108
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License Number State | NE
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 1822
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License Number State | NE
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 2138
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License Number State | NH
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