Provider Demographics
NPI:1386987402
Name:JACKSON, LAURA MARIE (FNP, CWCN)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP, CWCN
Other - Prefix:MISS
Other - First Name:LAURA
Other - Middle Name:MARIE
Other - Last Name:MOEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, FNP
Mailing Address - Street 1:PO BOX 2276
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8347
Mailing Address - Country:US
Mailing Address - Phone:360-430-7448
Mailing Address - Fax:
Practice Address - Street 1:3710 SW US VETERANS HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2964
Practice Address - Country:US
Practice Address - Phone:503-220-8262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201250183NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily