Provider Demographics
NPI:1568855724
Name:JACKSON, LARRY JR
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:826 WARFIELD PL
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40505-3612
Mailing Address - Country:US
Mailing Address - Phone:859-421-2250
Mailing Address - Fax:
Practice Address - Street 1:826 WARFIELD PL
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40505-3612
Practice Address - Country:US
Practice Address - Phone:859-421-2250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-12
Last Update Date:2015-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer