Provider Demographics
NPI:1174352280
Name:JACKSON, LATRICE
Entity type:Individual
Prefix:MISS
First Name:LATRICE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14200 S PARNELL AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60827-2313
Mailing Address - Country:US
Mailing Address - Phone:708-668-5449
Mailing Address - Fax:
Practice Address - Street 1:2010 216TH ST
Practice Address - Street 2:
Practice Address - City:SAUK VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60411-4506
Practice Address - Country:US
Practice Address - Phone:708-668-5449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041398810163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse