Provider Demographics
NPI:1497465009
Name:JACKSON, KASSIDY LYNN
Entity Type:Individual
Prefix:
First Name:KASSIDY
Middle Name:LYNN
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 1:2904 BETSY CT
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47720-5913
Mailing Address - Country:US
Mailing Address - Phone:812-431-0718
Mailing Address - Fax:
Practice Address - Street 1:4000 S TULIP TREE DR
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IN
Practice Address - Zip Code:47670-2300
Practice Address - Country:US
Practice Address - Phone:812-387-2938
Practice Address - Fax:812-387-2015
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99115773A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist