Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1043611775 |
---|---|
Provider Name | La Toya Jackson |
First Address | Los Angeles, CA 90017-1466 |
Second Address | Los Angeles, CA 90017-1466 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/09/2014 |
Last Update Date | 12/09/2014 |