Provider Demographics
NPI:1912639873
Name:JACKSON, LAUREN NICOLE
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:NICOLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3317 WOOD PLANK RD APT 203
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-2584
Mailing Address - Country:US
Mailing Address - Phone:760-994-9304
Mailing Address - Fax:
Practice Address - Street 1:650 EAST PWKY SOUTH
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104
Practice Address - Country:US
Practice Address - Phone:760-994-9304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-29
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant