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General NPI Number Information
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NPI Number | 1922500289
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Entity Type | Individual
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Provider Name | LATORIA NICOLE JACKSON
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Gender | Female
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Dates
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Enumeration Date | 03/02/2018
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Last Update Date | 03/02/2018
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Provider Practice Location Address
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Address Line | 4150 ALEXIS CT
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City | LOGANVILLE
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State | GA
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Zip | 30052-9070
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Country | US
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Telephone | 678-671-0078
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Fax | 888-948-2083
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Provider Business Mailing Address
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Address Line | 4150 ALEXIS CT
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City | LOGANVILLE
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State | GA
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Zip | 30052-9070
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Country | US
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Telephone | 678-671-0078
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Fax | 888-948-2083
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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 | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number |
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Taxonomy #4
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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Taxonomy #5
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Taxonomy Code | 261QA0600X
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Taxonomy Name | Adult Day Care Clinic/Center
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License Number |
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Taxonomy #6
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Taxonomy Code | 261QD1600X
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Taxonomy Name | Developmental Disabilities Clinic/Center
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License Number |
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Taxonomy #7
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Taxonomy Code | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number |
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Taxonomy #8
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number |
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Taxonomy #9
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #10
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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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Taxonomy #11
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Taxonomy Code | 373H00000X
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Taxonomy Name | Day Training/Habilitation Specialist
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License Number |
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Taxonomy #12
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Taxonomy Code | 343900000X
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Taxonomy Name | Non-emergency Medical Transport (VAN)
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License Number |
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