Provider Demographics
NPI:1528565710
Name:JACKSON, LORI (NP-C)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17115 MONROE DR NW
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-4307
Mailing Address - Country:US
Mailing Address - Phone:612-239-3393
Mailing Address - Fax:
Practice Address - Street 1:934 MAIN ST
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE ISLAND
Practice Address - State:AK
Practice Address - Zip Code:99591
Practice Address - Country:US
Practice Address - Phone:907-859-2254
Practice Address - Fax:907-859-2252
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-12
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK130523363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily