Healthcare Provider Details

I. General information

NPI: 1720901648
Provider Name (Legal Business Name): JACKSON WEAVER MAY DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 S BROADWAY
LEXINGTON KY
40504-2701
US

IV. Provider business mailing address

1221 S BROADWAY
LEXINGTON KY
40504-2771
US

V. Phone/Fax

Practice location:
  • Phone: 859-258-8519
  • Fax: 859-258-8592
Mailing address:
  • Phone: 859-258-6200
  • Fax: 859-258-6203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number009570
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: