Basic Information
| Provider Information | |||||||||
| NPI: | 1245901180 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | LATRELL | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 NOBLE DR | ||||||||
| Address2: | |||||||||
| City: | WOOSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446915353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302643232 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2803 AKRON RD | ||||||||
| Address2: | |||||||||
| City: | WOOSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446917904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302643232 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2021 | ||||||||
| LastUpdateDate: | 09/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.