Healthcare Provider Details

I. General information

NPI: 1902325244
Provider Name (Legal Business Name): LAUREN ELIZABETH JACKSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2017
Last Update Date: 12/23/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

857 GRAHAM RD
CUYAHOGA FALLS OH
44221-1170
US

IV. Provider business mailing address

857 GRAHAM RD
CUYAHOGA FALLS OH
44221-1170
US

V. Phone/Fax

Practice location:
  • Phone: 330-923-9585
  • Fax:
Mailing address:
  • Phone: 330-923-9585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberAPP-000115333
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: