Provider Demographics
NPI:1073184099
Name:JACKSON, LORI LEE (RN, CDCES)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:LEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 E 24TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3959
Mailing Address - Country:US
Mailing Address - Phone:612-721-9872
Mailing Address - Fax:612-721-2904
Practice Address - Street 1:1315 E 24TH ST STE 1
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3959
Practice Address - Country:US
Practice Address - Phone:612-721-9872
Practice Address - Fax:612-721-2904
Is Sole Proprietor?:No
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2459891163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator