Provider Demographics
NPI:1821278177
Name:JACKSON, LAURA LOUISE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:LOUISE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 JASON LN
Mailing Address - Street 2:
Mailing Address - City:WHEELERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45694-8463
Mailing Address - Country:US
Mailing Address - Phone:740-574-0659
Mailing Address - Fax:
Practice Address - Street 1:10 JASON LN
Practice Address - Street 2:
Practice Address - City:WHEELERSBURG
Practice Address - State:OH
Practice Address - Zip Code:45694-8463
Practice Address - Country:US
Practice Address - Phone:740-574-0659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-04
Last Update Date:2007-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-2-19610183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist