Provider Demographics
NPI:1508061607
Name:JACKSON, LAURA RENEE (CRNA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:RENEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 EAST TC JESTER
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77008
Mailing Address - Country:US
Mailing Address - Phone:713-864-0806
Mailing Address - Fax:
Practice Address - Street 1:17080 RED OAK DRIVE
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090
Practice Address - Country:US
Practice Address - Phone:832-724-4326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX651720367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00441171OtherRAILROAD MEDICARE
TX185608001Medicaid
TX87941UOtherBLUE CROSS PROVIDER ID
8J6224Medicare PIN