Individual
LATORIA CLARK-JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LPN
Contact information
Practice address
12802 KINGS LAKE DR, GIBSONTON, FL 33534-3907
(813) 400-4038
Mailing address
12802 KINGS LAKE DR, GIBSONTON, FL 33534-3907
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
PN5151340
FL
Other
Enumeration date
07/08/2020
Last updated
07/08/2020
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