Basic Information
| Provider Information | |||||||||
| NPI: | 1487949400 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | ELIZABETH EVANS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EVANS | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4401 PENN AVENUE, | ||||||||
| Address2: | AOB, SUITE 5400 | ||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4126925285 | ||||||||
| FaxNumber: | 4126927231 | ||||||||
| Practice Location | |||||||||
| Address1: | 4401 PENN AVENUE, | ||||||||
| Address2: | AOB, SUITE 5400 | ||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4126925285 | ||||||||
| FaxNumber: | 4126927231 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2011 | ||||||||
| LastUpdateDate: | 07/31/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MT199566 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.