MEDICARE: LATISHA JACKSON LMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	39005380A	IN

General Provider Information

NPI Number	:	1861977639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATISHA JACKSON LMHC

Provider Business Mailing Address
First Line	:	2201 E 46TH ST STE 108
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46205-1449
Country	:	US
Telephone Number	:	317-561-0390
Fax Number	:

Provider Business Practice Location Address
First Line	:	2201 E 46TH ST STE 108
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46205-1449
Country	:	US
Telephone Number	:	317-561-0390
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2018
Last Update Date	:	07/24/2025

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