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General NPI Number Information
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NPI Number | 1497208987
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Entity Type | Individual
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Provider Name | LAURA PERMELIA JACKSON M.S.ED.,ATC, LAT
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Gender | Female
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Dates
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Enumeration Date | 08/01/2016
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Last Update Date | 08/01/2016
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Provider Practice Location Address
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Address Line | 3300 AIRPORT ROAD
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City | SOUTHERN PINES
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State | NC
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Zip | 28387
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Country | US
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Telephone | 910-692-6920
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 290
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City | SOUTHERN PINES
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State | NC
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Zip | 28388-0290
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Country | US
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Telephone | 910-692-6920
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 002200
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AL3704
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License Number State | FL
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