Provider Demographics
NPI:1962005892
Name:JACKSON, LINDSAY
Entity Type:Individual
Prefix:
First Name:LINDSAY
Middle Name:
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 1:1085 CANAAN HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:WV
Mailing Address - Zip Code:26260-8007
Mailing Address - Country:US
Mailing Address - Phone:304-851-6643
Mailing Address - Fax:
Practice Address - Street 1:1085 CANAAN HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:WV
Practice Address - Zip Code:26260-8007
Practice Address - Country:US
Practice Address - Phone:304-851-6643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-22
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician