Provider Demographics
NPI:1235430257
Name:JACKSON, LORI-ANN MICHELLE (DPT)
Entity Type:Individual
Prefix:
First Name:LORI-ANN
Middle Name:MICHELLE
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 1:12 HARTMAN PLZ
Mailing Address - Street 2:
Mailing Address - City:BUCKHANNON
Mailing Address - State:WV
Mailing Address - Zip Code:26201-2230
Mailing Address - Country:US
Mailing Address - Phone:304-473-0531
Mailing Address - Fax:
Practice Address - Street 1:116 MARKET ST
Practice Address - Street 2:
Practice Address - City:MANNINGTON
Practice Address - State:WV
Practice Address - Zip Code:26582-1131
Practice Address - Country:US
Practice Address - Phone:304-986-1568
Practice Address - Fax:304-986-1373
Is Sole Proprietor?:No
Enumeration Date:2010-11-08
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2846225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist