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General NPI Number Information
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NPI Number | 1487801775
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Entity Type | Individual
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Provider Name | LAURENA S JACKSON PHYSICIAN ASSISTANT
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Gender | Female
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Dates
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Enumeration Date | 08/19/2008
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Last Update Date | 08/19/2008
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Provider Practice Location Address
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Address Line | 300 FOUNTAIN ROAD
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City | ROCKY MOUNT
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State | NC
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Zip | 27802
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Country | US
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Telephone | 252-442-9712
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Fax | 252-442-1413
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Provider Business Mailing Address
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Address Line | 1713 SAGAMORE CT
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City | RALEIGH
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State | NC
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Zip | 27604-4743
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Country | US
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Telephone | 252-442-9712
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Fax | 252-442-1413
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 101493
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License Number State | NC
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