Provider Demographics
NPI:1407864978
Name:JACKSON, LAURA B (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:B
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LAURA
Other - Middle Name:ELAINE
Other - Last Name:BARNETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6239
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7037 ST ANDREWS ROAD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-1177
Practice Address - Country:US
Practice Address - Phone:803-732-0963
Practice Address - Fax:803-732-1406
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23898207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC238987Medicaid
SC238987Medicaid