Provider Demographics
NPI:1447493119
Name:JACKSON, LAUREN HOLT (MD)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:HOLT
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 N FRIENDSHIP RD
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-8690
Mailing Address - Country:US
Mailing Address - Phone:901-485-2032
Mailing Address - Fax:
Practice Address - Street 1:2507 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-3124
Practice Address - Country:US
Practice Address - Phone:270-442-8228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-10
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY46159207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology