Healthcare Provider Details

I. General information

NPI: 1710941869
Provider Name (Legal Business Name): BARBARA LYNN JACKSON MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 W MARKET ST SUITE 202
FAIRLAWN OH
44333-4202
US

IV. Provider business mailing address

1149 COURTLEIGH DR
AKRON OH
44313-6665
US

V. Phone/Fax

Practice location:
  • Phone: 330-869-2635
  • Fax: 330-869-8315
Mailing address:
  • Phone: 330-836-5363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number001413
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: