Provider Demographics
NPI:1760991509
Name:LYM, SARAH JACKSON (PA-C)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:JACKSON
Last Name:LYM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 11TH ST APT B
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-3757
Mailing Address - Country:US
Mailing Address - Phone:801-903-3797
Mailing Address - Fax:
Practice Address - Street 1:1100 3RD ST
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-3402
Practice Address - Country:US
Practice Address - Phone:503-815-2292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-25
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA185216207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine