Provider Demographics
NPI:1003256603
Name:JACKSON, LAURA E
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:E
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 1:2615 N PRICKETT RD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72022-7523
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2615 N PRICKETT RD
Practice Address - Street 2:SUITE 10
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-7523
Practice Address - Country:US
Practice Address - Phone:501-847-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist