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General NPI Number Information
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NPI Number | 1457844110
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Entity Type | Individual
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Provider Name | LAURA M JACKSON MS, CCC-SLP
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Gender | Female
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Dates
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Enumeration Date | 06/07/2018
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Last Update Date | 05/12/2022
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Provider Practice Location Address
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Address Line | 7090 COVENANT WOODS DR
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City | MECHANICSVILLE
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State | VA
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Zip | 23111-7025
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Country | US
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Telephone | 804-569-8000
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Fax |
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Provider Business Mailing Address
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Address Line | 8202 BEAGLE DR
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City | HENRICO
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State | VA
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Zip | 23228-3036
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Country | US
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Telephone | 423-718-2990
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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 | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 2202008528
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License Number State | VA
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