Provider Demographics
NPI:1760582720
Name:JACKSON, LAURA R (LPTA)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 HARRIS HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:TN
Mailing Address - Zip Code:37036-5450
Mailing Address - Country:US
Mailing Address - Phone:615-218-4094
Mailing Address - Fax:
Practice Address - Street 1:812 N CHARLOTTE ST
Practice Address - Street 2:
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-1009
Practice Address - Country:US
Practice Address - Phone:615-446-8046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN02023225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant