Basic Information
| Provider Information | |||||||||
| NPI: | 1346754348 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | LATONYA | ||||||||
| MiddleName: | MONIQUE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2607 LEDO RD | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317071211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299030022 | ||||||||
| FaxNumber: | 2299030025 | ||||||||
| Practice Location | |||||||||
| Address1: | 2607 LEDO RD | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317071211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299030022 | ||||||||
| FaxNumber: | 2299030025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2017 | ||||||||
| LastUpdateDate: | 11/29/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | LPN089401 | GA | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.