Provider Demographics
NPI:1629775879
Name:JACKSON, LAURA MONICA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MONICA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 ARNOLD AVE SW
Mailing Address - Street 2:
Mailing Address - City:BOLLING AFB
Mailing Address - State:DC
Mailing Address - Zip Code:20032-7677
Mailing Address - Country:US
Mailing Address - Phone:915-300-8361
Mailing Address - Fax:
Practice Address - Street 1:5037 CALL PL SE APT 200
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-7693
Practice Address - Country:US
Practice Address - Phone:202-904-8241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-08
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion