Provider Demographics
NPI:1497208987
Name:JACKSON, LAURA PERMELIA (MSED,ATC, LAT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:PERMELIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSED,ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 290
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28388-0290
Mailing Address - Country:US
Mailing Address - Phone:910-692-6920
Mailing Address - Fax:
Practice Address - Street 1:3300 AIRPORT ROAD
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387
Practice Address - Country:US
Practice Address - Phone:910-692-6920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-01
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0022002255A2300X
FLAL37042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer