Organization
BUNDLE BEHAVIOR
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LATEASHA C JACKSON CERT HAIR LOSS SPECI (OWNER)
(913) 709-1122
Entity
Organization
Contact information
Practice address
1110 N 47TH ST, KANSAS CITY, KS 66102-1702
(913) 287-0880
Mailing address
3227 N 103RD TER, KANSAS CITY, KS 66109-5814
(913) 709-1122
Taxonomy
Speciality
Code
Description
License number
State
1744P3200X
Prosthetics Case Management
Primary
—
—
Other
Enumeration date
12/31/2015
Last updated
12/31/2015
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