Provider Demographics
NPI:1083320329
Name:JACKSON, KEYLEY LYNNE (DPT)
Entity Type:Individual
Prefix:
First Name:KEYLEY
Middle Name:LYNNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1267 ENTERPRISE WAY NW STE B
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35806-4472
Mailing Address - Country:US
Mailing Address - Phone:256-713-1872
Mailing Address - Fax:
Practice Address - Street 1:12181 COUNTY LINE RD STE 150
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-7740
Practice Address - Country:US
Practice Address - Phone:256-489-1100
Practice Address - Fax:256-429-2197
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2-1194225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist