Provider Demographics
NPI:1952478950
Name:JACKSON, LAURENCE E (MD)
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 9TH STREET
Mailing Address - Street 2:ROOM 205, MAILSTOP 2-3
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:94244-2020
Mailing Address - Country:US
Mailing Address - Phone:916-654-3482
Mailing Address - Fax:916-653-4587
Practice Address - Street 1:3102 E. HIGHLAND AVENUE
Practice Address - Street 2:PATTON STATE HOSPITAL
Practice Address - City:PATTON
Practice Address - State:CA
Practice Address - Zip Code:92369
Practice Address - Country:US
Practice Address - Phone:909-425-7000
Practice Address - Fax:909-425-6635
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG384082084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry