Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 11988 | NC |
NPI | 1013585447 |
---|---|
Provider Name | Latasha Monique Jackson |
First Address | China Grove, NC 28023-8601 |
Second Address | Concord, NC 28025-4757 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/06/2021 |
Last Update Date | 13/06/2021 |