Provider Demographics
NPI:1083760938
Name:JACKSON, LORA A (NP)
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4185 E WILDCAT RESERVE PKWY
Mailing Address - Street 2:STE 100
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80126-6801
Mailing Address - Country:US
Mailing Address - Phone:303-791-7896
Mailing Address - Fax:303-791-8152
Practice Address - Street 1:4185 E WILDCAT RESERVE PKWY
Practice Address - Street 2:STE 100
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80126-6801
Practice Address - Country:US
Practice Address - Phone:303-791-7896
Practice Address - Fax:303-791-8152
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO78444363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO78444OtherNURSE LICENSE