Provider Demographics
NPI:1649867656
Name:JACKSON, LAUREN LEACHMAN (FNP)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:LEACHMAN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 PECK LN
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8691
Mailing Address - Country:US
Mailing Address - Phone:757-724-2520
Mailing Address - Fax:
Practice Address - Street 1:20209 SENTARA WAY STE 100
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:VA
Practice Address - Zip Code:23314-3573
Practice Address - Country:US
Practice Address - Phone:757-772-6125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-23
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024180676363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily