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General NPI Number Information
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NPI Number | 1649867656
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Entity Type | Individual
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Provider Name | LAUREN LEACHMAN JACKSON FNP
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Gender | Female
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Dates
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Enumeration Date | 12/23/2020
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Last Update Date | 01/30/2025
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Provider Practice Location Address
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Address Line | 20209 SENTARA WAY STE 100
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City | CARROLLTON
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State | VA
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Zip | 23314-3573
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Country | US
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Telephone | 757-772-6125
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Fax |
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Provider Business Mailing Address
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Address Line | 224 PECK LN
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City | SUFFOLK
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State | VA
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Zip | 23434-8691
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Country | US
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Telephone | 757-724-2520
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 0024180676
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License Number State | VA
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