=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336483379
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURAINE M JACKSON FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2012
-----------------------------------------------------
Last Update Date | 06/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3212 N WINDSONG DR SUITE 200
-----------------------------------------------------
City | PRESCOTT VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86314-2255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-583-1000
-----------------------------------------------------
Fax | 866-751-4157
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 330 SEVEN SPRINGS WAY
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-5098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-920-7782
-----------------------------------------------------
Fax | 615-920-8775
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | RN098038
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------