Provider Demographics
NPI:1154913937
Name:JACKSON, LYDIA GAIL (BS, MS)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:GAIL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:BS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2691 VINTAGE AVE SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-2534
Mailing Address - Country:US
Mailing Address - Phone:503-881-3098
Mailing Address - Fax:
Practice Address - Street 1:3410 CHERRY AVE NE
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4924
Practice Address - Country:US
Practice Address - Phone:503-602-8384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator