Provider Demographics
NPI:1154735611
Name:JACKSON, COREY (DPT)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:MR
Other - First Name:COREY
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPT
Mailing Address - Street 1:1650 LYNDON FARM CT STE 300
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5005
Mailing Address - Country:US
Mailing Address - Phone:316-263-0003
Mailing Address - Fax:
Practice Address - Street 1:3460 N RIDGE RD STE 80
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-1223
Practice Address - Country:US
Practice Address - Phone:316-202-0340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-04877225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist