MEDICARE: LYNN C JACKSON P.T.

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	225100000X	Physical Therapist	1113850	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	659558	OTHER	TX	BCBS PROVIDER #

General Provider Information

NPI Number	:	1689779522
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYNN C JACKSON P.T.

Provider Business Mailing Address
First Line	:	PO BOX 91419
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78709-1419
Country	:	US
Telephone Number	:	512-899-8508
Fax Number	:	512-899-9387

Provider Business Practice Location Address
First Line	:	6012 W WILLIAM CANNON DR
Second Line	:	BLDG C
City	:	AUSTIN
State	:	TX
Zip	:	78749-1980
Country	:	US
Telephone Number	:	512-899-8508
Fax Number	:	512-899-9387

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

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	07/08/2007

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