Provider Demographics
NPI:1740673805
Name:JACKSON, LORIE G (PTA)
Entity type:Individual
Prefix:MS
First Name:LORIE
Middle Name:G
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 ADA AVE
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-1432
Mailing Address - Country:US
Mailing Address - Phone:502-257-2497
Mailing Address - Fax:
Practice Address - Street 1:1800 BLUEGRASS AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1130
Practice Address - Country:US
Practice Address - Phone:502-361-2301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA02653225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant