Basic Information
| Provider Information | |||||||||
| NPI: | 1942267273 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | LAURICE | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 652F CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038203414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037492346 | ||||||||
| FaxNumber: | 6039530066 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 WINTER ST | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038673153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6033325500 | ||||||||
| FaxNumber: | 6033320410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LX0001X | 010948-23-03 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 00000875 | 05 | NH | MEDICAID |