Provider Demographics
NPI:1073725321
Name:JACKSON, LORREN (MD)
Entity Type:Individual
Prefix:DR
First Name:LORREN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415-1518
Mailing Address - Country:US
Mailing Address - Phone:612-215-6300
Mailing Address - Fax:
Practice Address - Street 1:530 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1518
Practice Address - Country:US
Practice Address - Phone:612-215-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN52249207ZF0201X
CAA86673207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology