Provider Demographics
NPI:1487995718
Name:JACKSON, LAURA ANN (NP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:A
Other - Last Name:MARCINCZYK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP BC
Mailing Address - Street 1:1950 GLENN MITCHELL DR STE 200
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-0168
Mailing Address - Country:US
Mailing Address - Phone:757-507-0600
Mailing Address - Fax:757-589-3785
Practice Address - Street 1:1950 GLENN MITCHELL DR STE 200
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-0168
Practice Address - Country:US
Practice Address - Phone:757-507-0600
Practice Address - Fax:757-589-3785
Is Sole Proprietor?:No
Enumeration Date:2013-03-12
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024170719363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1487995718Medicaid