Individual
LATORIA NICOLE JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
4150 ALEXIS CT, LOGANVILLE, GA 30052-9070
(678) 671-0078
(888) 948-2083
Mailing address
4150 ALEXIS CT, LOGANVILLE, GA 30052-9070
(678) 671-0078
(888) 948-2083
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
—
—
251B00000X
Case Management Agency
—
—
251C00000X
Developmentally Disabled Services Day Training Agency
—
—
251S00000X
Community/Behavioral Health Agency
—
—
261QA0600X
Adult Day Care Clinic/Center
—
—
261QD1600X
Developmental Disabilities Clinic/Center
—
—
3104A0625X
Assisted Living Facility (Mental Illness)
—
—
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
—
—
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
—
—
343900000X
Non-emergency Medical Transport (VAN)
Primary
—
—
372600000X
Adult Companion
—
—
373H00000X
Day Training/Habilitation Specialist
—
—
Other
Enumeration date
03/02/2018
Last updated
03/02/2018
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