MEDICARE: LAURA JACKSON

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	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1659159630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA JACKSON

Provider Business Mailing Address
First Line	:	3256 W 25TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44109-1637
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3256 W 25TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44109-1637
Country	:	US
Telephone Number	:	216-632-2714
Fax Number	:

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

Provider Enumeration Date	:	09/20/2023
Last Update Date	:	09/20/2023

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Directions to “ LAURA JACKSON ” Practice Location

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