Provider Demographics
NPI:1083662167
Name:JACKSON, LAURA (LPT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5318 HIGHGATE DR
Mailing Address - Street 2:SUITE 134
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-6630
Mailing Address - Country:US
Mailing Address - Phone:919-237-3802
Mailing Address - Fax:919-237-3807
Practice Address - Street 1:5318 HIGHGATE DR
Practice Address - Street 2:SUITE 134
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-6630
Practice Address - Country:US
Practice Address - Phone:919-237-3802
Practice Address - Fax:919-237-3807
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9819225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7211932Medicaid
NC7211932Medicaid