Provider Demographics
NPI:1417282955
Name:JACKSON, LINDA CAROL (PTA)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:CAROL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 S COUNTY ROAD 300 W
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47302-8833
Mailing Address - Country:US
Mailing Address - Phone:765-759-8664
Mailing Address - Fax:
Practice Address - Street 1:9200 S COUNTY ROAD 300 W
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47302-8833
Practice Address - Country:US
Practice Address - Phone:765-759-8664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-15
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002171A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant