Provider Demographics
NPI:1356306203
Name:JACKSON, GREGORY LEE (MS, ATC)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:LEE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3821 EVERETTS DL
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40514-1185
Mailing Address - Country:US
Mailing Address - Phone:859-351-6789
Mailing Address - Fax:
Practice Address - Street 1:3821 EVERETTS DL
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40514-1185
Practice Address - Country:US
Practice Address - Phone:859-351-6789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer