Provider Demographics
NPI:1578007415
Name:JACKSON, LACY
Entity Type:Individual
Prefix:
First Name:LACY
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 1:810 N CALVERT ST
Mailing Address - Street 2:APT 6
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-3749
Mailing Address - Country:US
Mailing Address - Phone:512-864-5221
Mailing Address - Fax:
Practice Address - Street 1:810 N CALVERT ST
Practice Address - Street 2:APT 6
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-3749
Practice Address - Country:US
Practice Address - Phone:512-864-5221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07487225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist