Provider Demographics
NPI:1346678331
Name:JACKSON, LYNDZIE
Entity Type:Individual
Prefix:
First Name:LYNDZIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 269084
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-9084
Mailing Address - Country:US
Mailing Address - Phone:623-398-8072
Mailing Address - Fax:623-398-8235
Practice Address - Street 1:9127 W THUNDERBIRD RD
Practice Address - Street 2:BLDG 1 SUITE 101
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4887
Practice Address - Country:US
Practice Address - Phone:480-222-0655
Practice Address - Fax:480-222-1457
Is Sole Proprietor?:No
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10438225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist