Provider Demographics
NPI:1366233900
Name:JACKSON, LA TASHA
Entity type:Individual
Prefix:
First Name:LA TASHA
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 1:286 EUCLID AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92114-3612
Mailing Address - Country:US
Mailing Address - Phone:619-204-0074
Mailing Address - Fax:
Practice Address - Street 1:286 EUCLID AVE STE 206
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92114-3612
Practice Address - Country:US
Practice Address - Phone:619-737-2769
Practice Address - Fax:619-737-2769
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-14
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner