Provider Demographics
NPI:1598322364
Name:JACKSON, BOBBI JO
Entity Type:Individual
Prefix:
First Name:BOBBI
Middle Name:JO
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 1:825 APACHE TRL
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-2711
Mailing Address - Country:US
Mailing Address - Phone:859-619-3077
Mailing Address - Fax:
Practice Address - Street 1:825 APACHE TRL
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-2711
Practice Address - Country:US
Practice Address - Phone:859-619-3077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid