Provider Demographics
NPI:1841849759
Name:JACKS, LINDSEY S (COTA)
Entity type:Individual
Prefix:
First Name:LINDSEY
Middle Name:S
Last Name:JACKS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:LINDSEY
Other - Middle Name:S
Other - Last Name:WINESBURG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 PONDEROSA RD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-2502
Mailing Address - Country:US
Mailing Address - Phone:307-634-7986
Mailing Address - Fax:
Practice Address - Street 1:1200 E 21ST ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3951
Practice Address - Country:US
Practice Address - Phone:918-634-7986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1203224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant