Provider Demographics
NPI:1487949400
Name:JACKSON, LAURA ELIZABETH EVANS (MD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ELIZABETH EVANS
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LAURA
Other - Middle Name:ELIZABETH
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4401 PENN AVENUE,
Mailing Address - Street 2:AOB, SUITE 5400
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15224
Mailing Address - Country:US
Mailing Address - Phone:412-692-5285
Mailing Address - Fax:412-692-7231
Practice Address - Street 1:4401 PENN AVENUE,
Practice Address - Street 2:AOB, SUITE 5400
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224
Practice Address - Country:US
Practice Address - Phone:412-692-5285
Practice Address - Fax:412-692-7231
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT199566208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics