Provider Demographics
NPI:1457844110
Name:JACKSON, LAURA M (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8202 BEAGLE DR
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23228-3036
Mailing Address - Country:US
Mailing Address - Phone:423-718-2990
Mailing Address - Fax:
Practice Address - Street 1:7090 COVENANT WOODS DR
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23111-7025
Practice Address - Country:US
Practice Address - Phone:804-569-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-07
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202008528235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist