Provider Demographics
NPI:1942267273
Name:JACKSON, LAURICE (ARNP)
Entity Type:Individual
Prefix:
First Name:LAURICE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652F CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03820-3414
Mailing Address - Country:US
Mailing Address - Phone:603-749-2346
Mailing Address - Fax:603-953-0066
Practice Address - Street 1:40 WINTER ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03867-3153
Practice Address - Country:US
Practice Address - Phone:603-332-5500
Practice Address - Fax:603-332-0410
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH010948-23-03363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH00000875Medicaid
NHS93959Medicare UPIN
NH00000875Medicaid