MEDICARE: LAURA PERMELIA JACKSON M.S.ED.,ATC, LAT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	002200	NY
2	2255A2300X	Athletic Trainer	AL3704	FL

General Provider Information

NPI Number	:	1497208987
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA PERMELIA JACKSON M.S.ED.,ATC, LAT

Provider Business Mailing Address
First Line	:	PO BOX 290
Second Line	:
City	:	SOUTHERN PINES
State	:	NC
Zip	:	28388-0290
Country	:	US
Telephone Number	:	910-692-6920
Fax Number	:

Provider Business Practice Location Address
First Line	:	3300 AIRPORT ROAD
Second Line	:
City	:	SOUTHERN PINES
State	:	NC
Zip	:	28387
Country	:	US
Telephone Number	:	910-692-6920
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2016
Last Update Date	:	08/01/2016

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