Healthcare Provider Details

I. General information

NPI: 1316529241
Provider Name (Legal Business Name): LAUREN HALASE JACKSON MSN, APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2021
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 CHADWICK DR STE 300
JACKSON MS
39204-3470
US

IV. Provider business mailing address

421 CUMBERLAND CT
MADISON MS
39110-7375
US

V. Phone/Fax

Practice location:
  • Phone: 601-376-2857
  • Fax:
Mailing address:
  • Phone: 601-455-4893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number906902
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number904777
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: