Healthcare Provider Details

I. General information

NPI: 1811745458
Provider Name (Legal Business Name): LAURYN JACKSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2024
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6470 S HIGLEY RD
GILBERT AZ
85298-4341
US

IV. Provider business mailing address

PO BOX 932958
CLEVELAND OH
44193-0028
US

V. Phone/Fax

Practice location:
  • Phone: 480-809-2409
  • Fax:
Mailing address:
  • Phone: 615-425-4200
  • Fax: 615-425-4201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10391
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10391
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: