Provider Demographics
NPI:1689779522
Name:JACKSON, LYNN C (PT)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 91419
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78709-1419
Mailing Address - Country:US
Mailing Address - Phone:512-899-8508
Mailing Address - Fax:512-899-9387
Practice Address - Street 1:6012 W WILLIAM CANNON DR
Practice Address - Street 2:BLDG C
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749-1980
Practice Address - Country:US
Practice Address - Phone:512-899-8508
Practice Address - Fax:512-899-9387
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1113850225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX659558OtherBCBS PROVIDER #
TX650589Medicare ID - Type UnspecifiedMCR PROVIDER #