Provider Demographics
NPI:1336483379
Name:JACKSON, LAURAINE M (FNP-BC)
Entity Type:Individual
Prefix:
First Name:LAURAINE
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 SEVEN SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5098
Mailing Address - Country:US
Mailing Address - Phone:615-920-7782
Mailing Address - Fax:615-920-8775
Practice Address - Street 1:3212 N WINDSONG DR
Practice Address - Street 2:SUITE 200
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-2255
Practice Address - Country:US
Practice Address - Phone:928-583-1000
Practice Address - Fax:866-751-4157
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2017-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN098038363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily