Provider Demographics
NPI:1639699465
Name:JACKSON, LAURA ASHLYN BROOME (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ASHLYN BROOME
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:LAURA
Other - Middle Name:ASHLYN
Other - Last Name:BROOME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:209 BENNETTS GROVE LN
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3791
Mailing Address - Country:US
Mailing Address - Phone:704-996-3058
Mailing Address - Fax:
Practice Address - Street 1:620 JOHN PAUL JONES CIR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708-2111
Practice Address - Country:US
Practice Address - Phone:704-996-3058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36149183500000X
CT0013225183500000X
NC21072183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist