Provider Demographics
NPI:1760517999
Name:JACKSON, KAREN SYDNI (ATC)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:SYDNI
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1482 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-2131
Mailing Address - Country:US
Mailing Address - Phone:434-414-0632
Mailing Address - Fax:
Practice Address - Street 1:125 NATIONWIDE DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-4272
Practice Address - Country:US
Practice Address - Phone:434-200-6933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260007322255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer