Provider Demographics
NPI:1508062381
Name:JACKSON, LYNNE W (OTR)
Entity Type:Individual
Prefix:MS
First Name:LYNNE
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:585 LIBERTY HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-1673
Mailing Address - Country:US
Mailing Address - Phone:952-448-4482
Mailing Address - Fax:952-403-3979
Practice Address - Street 1:1661 PARK RIDGE DR
Practice Address - Street 2:CAPABLE KIDS
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-2841
Practice Address - Country:US
Practice Address - Phone:952-403-3987
Practice Address - Fax:952-403-3979
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN100096225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist