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General NPI Number Information
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NPI Number | 1922711993
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Entity Type | Individual
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Provider Name | LAURA RAE JACKAM P.A.
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Gender | Female
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Dates
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Enumeration Date | 01/04/2023
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Last Update Date | 10/21/2025
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Provider Practice Location Address
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Address Line | 4975 FOOTE RD. STE. #400
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City | MEDINA
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State | OH
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Zip | 44256-9048
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Country | US
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Telephone | 330-591-9038
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Fax | 330-722-8585
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Provider Business Mailing Address
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Address Line | 2000 AUBURN DR. STE. 350
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City | BEACHWOOD
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State | OH
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Zip | 44122-4327
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Country | US
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Telephone | 440-646-1600
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Fax | 440-646-1505
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 50.008854RX
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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Taxonomy #3
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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