Provider Demographics
NPI:1669845210
Name:JACKSON, ALLISON NICOLE (AT)
Entity Type:Individual
Prefix:MRS
First Name:ALLISON
Middle Name:NICOLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 WALLER DR
Mailing Address - Street 2:
Mailing Address - City:CRITTENDEN
Mailing Address - State:KY
Mailing Address - Zip Code:41030-8723
Mailing Address - Country:US
Mailing Address - Phone:859-803-3993
Mailing Address - Fax:
Practice Address - Street 1:190 WALLER DR
Practice Address - Street 2:
Practice Address - City:CRITTENDEN
Practice Address - State:KY
Practice Address - Zip Code:41030-8723
Practice Address - Country:US
Practice Address - Phone:859-803-3993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT. 0047572255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer