Provider Demographics
NPI:1871707596
Name:JACKSON, DANA LYNN (LPTA)
Entity type:Individual
Prefix:MRS
First Name:DANA
Middle Name:LYNN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1361 CAUSEY RD SE
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39653-7235
Mailing Address - Country:US
Mailing Address - Phone:601-810-3593
Mailing Address - Fax:601-384-1878
Practice Address - Street 1:113 MAIN ST.
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:MS
Practice Address - Zip Code:39653
Practice Address - Country:US
Practice Address - Phone:601-384-1898
Practice Address - Fax:601-384-1878
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA1972225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant