Provider Demographics
NPI:1972732816
Name:JACKSON, LYNDSAY MARIE (DPT)
Entity type:Individual
Prefix:
First Name:LYNDSAY
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:LYNDSAY
Other - Middle Name:MARIE
Other - Last Name:SHAFFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:320 JONES AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1414
Mailing Address - Country:US
Mailing Address - Phone:301-268-2427
Mailing Address - Fax:
Practice Address - Street 1:1200 J D ANDERSON DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3494
Practice Address - Country:US
Practice Address - Phone:304-598-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2758225100000X
WVPT2758225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist