MEDICARE: DR. LAURA B JACKSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	23898	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407864978
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURA B JACKSON MD

Provider Business Mailing Address
First Line	:	PO BOX 6069
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28289-6239
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7037 ST ANDREWS ROAD
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29212-1177
Country	:	US
Telephone Number	:	803-732-0963
Fax Number	:	803-732-1406

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	11/06/2020

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