Healthcare Provider Details

I. General information

NPI: 1326950858
Provider Name (Legal Business Name): LAVETTA E JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10207 ACKERLY TER
LANHAM MD
20706-2309
US

IV. Provider business mailing address

10207 ACKERLY TER
LANHAM MD
20706-2309
US

V. Phone/Fax

Practice location:
  • Phone: 240-271-3498
  • Fax: 443-203-3172
Mailing address:
  • Phone: 240-271-3498
  • Fax: 443-203-3172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: