Individual provider · NPI-1

Latoria Nicole Jackson

Non-emergency Medical Transport (VAN) · Loganville, GA

NPI number1922500289

StatusActive

Last updated in NPPESMar 2, 2018

Details

NPI: 1922500289
Entity type: Individual (NPI-1)
Name: Latoria Nicole Jackson
Sex: Female
Sole proprietor: Yes
Enumeration date: Mar 2, 2018
Last updated: Mar 2, 2018

Taxonomy and licenses

Taxonomy code	Description	License	State	Primary
343900000X	Non-emergency Medical Transport (VAN)	–	–	Yes
171M00000X	Case Manager/Care Coordinator	–	–
251B00000X	Case Management	–	–
251C00000X	Day Training, Developmentally Disabled Services	–	–
251S00000X	Community/Behavioral Health	–	–
261QA0600X	Clinic/Center, Adult Day Care	–	–
261QD1600X	Clinic/Center, Developmental Disabilities	–	–
3104A0625X	Assisted Living Facility, Assisted Living, Mental Illness	–	–
320600000X	Residential Treatment Facility, Intellectual and/or Developmental Disabilities	–	–
320900000X	Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities	–	–
372600000X	Adult Companion	–	–
373H00000X	Day Training/Habilitation Specialist	–	–

Practice location

4150 Alexis Ct
Loganville, GA 30052-9070

Phone 678-671-0078 · Fax 888-948-2083

Mailing address

4150 Alexis Ct
Loganville, GA 30052-9070

Phone 678-671-0078 · Fax 888-948-2083

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