MEDICARE: LYDIA LANE JACKSON PA C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA198	AL

General Provider Information

NPI Number	:	1487642161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYDIA LANE JACKSON PA C

Provider Business Mailing Address
First Line	:	7028 CROSS BEND CT
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36117-2445
Country	:	US
Telephone Number	:	334-213-6441
Fax Number	:

Provider Business Practice Location Address
First Line	:	215 PERRY HILL RD
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36109-3725
Country	:	US
Telephone Number	:	334-272-4670
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/07/2005
Last Update Date	:	07/13/2007

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