| NPI | 1093878191 |
|---|---|
| Professional Name | LARRY RANDOLPH JACKSON |
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 163WP0808X Registered Nurse, Psych/Mental Health (Licence: SC 56879) |
| Enumeration Date | 2006-12-19 |
| Last Update Date | 2007-07-08 |