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General NPI Number Information
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NPI Number | 1942050059
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Entity Type | Individual
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Provider Name | MICHAEL LATRELLE JACKSON
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Gender | Male
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Dates
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Enumeration Date | 03/25/2024
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Last Update Date | 05/20/2024
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Provider Practice Location Address
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Address Line | 1156 BANNOCKBURN AVE
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City | ROCK HILL
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State | SC
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Zip | 29732-1095
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Country | US
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Telephone | 803-718-5292
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Fax |
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Provider Business Mailing Address
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Address Line | 1156 BANNOCKBURN AVE
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City | ROCK HILL
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State | SC
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Zip | 29732-1095
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Country | US
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Telephone | 803-718-5292
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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 | 374U00000X
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Taxonomy Name | Home Health Aide
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License Number | IHCP-2092
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License Number State | SC
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