Provider Demographics
NPI:1598018962
Name:JACKSON, LAURA (CO)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 PROFESSIONAL PARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-5516
Mailing Address - Country:US
Mailing Address - Phone:704-799-9825
Mailing Address - Fax:704-799-9826
Practice Address - Street 1:123 PROFESSIONAL PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-5516
Practice Address - Country:US
Practice Address - Phone:704-799-9825
Practice Address - Fax:704-799-9826
Is Sole Proprietor?:No
Enumeration Date:2012-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist