Provider Demographics
NPI:1679346894
Name:JACKSON, LATASHA (RN)
Entity type:Individual
Prefix:
First Name:LATASHA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5330 E 31ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-5076
Mailing Address - Country:US
Mailing Address - Phone:918-600-3100
Mailing Address - Fax:
Practice Address - Street 1:5330 E 31ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-5076
Practice Address - Country:US
Practice Address - Phone:918-600-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-31
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0111570171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator