Individual
LATOYA JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
5742 JODPHUR CT, TALLAHASSEE, FL 32303-6748
(850) 728-3413
Mailing address
5742 JODPHUR CT, TALLAHASSEE, FL 32303-6748
(850) 728-3413
Taxonomy
Speciality
Code
Description
License number
State
1710I1002X
Independent Duty Corpsman
—
—
302R00000X
Health Maintenance Organization
—
—
305S00000X
Point of Service
Primary
—
—
Other
Enumeration date
05/11/2017
Last updated
05/11/2017
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