Healthcare Provider Details

I. General information

NPI: 1124003363
Provider Name (Legal Business Name): LAURIE J JACKSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17207 KUYKENDAHL RD 200
SPRING TX
77379-8423
US

IV. Provider business mailing address

17207 KUYKENDAHL RD 200
SPRING TX
77379-8423
US

V. Phone/Fax

Practice location:
  • Phone: 832-698-5320
  • Fax: 832-698-5171
Mailing address:
  • Phone: 832-698-5320
  • Fax: 832-698-5171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number463521
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: