Provider Demographics
NPI:1871779256
Name:LYNN JACKSON, PT, PC
Entity type:Organization
Organization Name:LYNN JACKSON, PT, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT ,PC
Authorized Official - Phone:512-899-8508
Mailing Address - Street 1:PO BOX 91419
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78709-1419
Mailing Address - Country:US
Mailing Address - Phone:512-899-8508
Mailing Address - Fax:512-899-9387
Practice Address - Street 1:6012 W WILLIAM CANNON DR
Practice Address - Street 2:BLDG C-101
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749-1980
Practice Address - Country:US
Practice Address - Phone:512-899-8508
Practice Address - Fax:512-899-9387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1113850225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1689779522OtherNPI-INDIVIDUAL