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General NPI Number Information
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NPI Number | 1063357473
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Entity Type | Individual
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Provider Name | LAURAN DEKEASE JACKSON
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Gender | Female
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Dates
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Enumeration Date | 04/22/2026
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Last Update Date | 04/22/2026
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Provider Practice Location Address
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Address Line | 10543 SOUTH CRATER ROAD
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City | PETERSBURG
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State | VA
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Zip | 23805
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Country | US
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Telephone | 804-481-5259
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Fax |
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Provider Business Mailing Address
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Address Line | 10543 SOUTH CRATER ROAD
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City | PETERSBURG
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State | VA
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Zip | 23805
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Country | US
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Telephone | 804-481-5259
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2083T0002X
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Taxonomy Name | Medical Toxicology (Preventive Medicine) Physician
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License Number | 1401115318
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License Number State | VA
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