Provider Demographics
NPI:1215758420
Name:JACKSON, LARA LEE (EDS)
Entity type:Individual
Prefix:MRS
First Name:LARA
Middle Name:LEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10440 INDIAN CREEK RD S
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46259-1451
Mailing Address - Country:US
Mailing Address - Phone:317-803-8112
Mailing Address - Fax:317-803-8197
Practice Address - Street 1:10440 INDIAN CREEK RD S
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46259-1451
Practice Address - Country:US
Practice Address - Phone:317-803-8112
Practice Address - Fax:317-803-8197
Is Sole Proprietor?:No
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1482318103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool